WHO report on the global tobacco epidemic, 2019: offer help to quit tobacco use

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Printed in Switzerland Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe The Georgian parliament votes for a tobacco control bill, 2017. Plain packaging guidelines, Uruguay. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.05 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). as many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. an additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. at the same time, two countries dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control, while australia has not reported the number of staff in 2018. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NaTIONaL TOBaCCO CONTrOL PrOGrammES PrOGrESS IN NaTIONaL TOBaCCO CONTrOL PrOGrammES (2008–2018) Decentralizing nTCP authority is important adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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(http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some or many 3 appropriate characteristics 4 Or large warnings 5 missing many 6 appropriate characteristics 4 medium size warnings 2 with all appropriate characteristics 4 Or large warnings 5 missing some 3 appropriate characteristics 4 Large warnings 5 with all appropriate characteristics 4 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 5 average of front and back of the package is at least 50%. 6 Four or more. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 79.9% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Special thanks to Kelvin Khow Chuan Heng and vera Luiza da Costa e Silva from the World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of alexandra Choi and Pirathap Loganathan. administrative support was provided by: amal amoune-Naal, miriamjoy aryee-Quansah, Gareth Burns, rosane De Barros Serrao, Luis madge, Zahra ali Piazza, Ochid romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, rebecca röttger and anastasia vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by alison Commar, with support from Soothesuk Kusumpa and Elza anna Barzdina. The prevalence estimates were calculated by alison Commar, with the collaboration of ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, merideth Lewis-Cooney, alexandra Choi and Tuba asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba ayoub, annette m David, madmoud m Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, min Kyung Lim, Tim mcafee, Pratima murthy, yvonne Olando, Jennifer Percival, Olivier randriamahazosoa, martin raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana yunibhand. Other aspects of report were greatly enriched by inputs from Jorge alday, anna Gilmore, maciej Goniewicz, Brian King, Gan Quan. analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by anne-marie Perucic and robert Totanes with support from mark Goodchild, roberto Iglesias, Dora Nicolazzo and alejandro ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and adrienne Pizatella of the Bloomberg Initiative to reduce Tobacco use for their collaboration. Our thanks also go to Florence rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and alexey Kotov, as well as: Luiza amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, vaishakhi mallik, Irina morozova, Sandra mullin, Nandita murukutla, Nguyen Nhung, rebecca Perl, ancha rachfiansyah, Benjamin Gonzalez rubio, md. Nasir uddin and Winnie Chen yu. Special thanks also to the Campaign for Tobacco Free Kids, especially maria Carmona, Kaitlin Donley and monique muggli for their constructive exchange of tobacco control information and legislation. Thanks also to rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from alboum for the quality and speed with which we received the translations of legislation. vinayak Prasad, Douglas Bettcher and vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors aubra Godwin and angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-marie Dangou, Deowan mohee, Nivo ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco armada Perez, adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed mahfuzul Huq, Tara mona Kessaram, arvind rinkoo (Bangladesh), Kencho Wangdi (Bhutan), atul Dahal, Hye ran ri (DPr Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (maldives), myo Paing (myanmar), Lonim Dixit, md Khurshid alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: angela Ciobanu, Elizaveta Lebedeva, Kristina mauer-Stender. WHO Eastern Mediterranean Region: raouf alebshehy, Fatimah El-awa, Heba Fouad, miriam Gordon, radwa el Wakil. WHO Western Pacific Region: melanie aldeon, ramon de Guzman, mina Kashiwabara, Kate Lannan, Hai-rim Shin, Daravuth yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), ada moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic republic), Paul Soo, Narwant Kaur (malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (mongolia), anna maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi viki (Samoa), Kirsten Frandsen (Solomon Islands), yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (viet Nam). WHO Headquarters Geneva: virginia arnold, Ferranda Cotado, melanie Cowan, Hicham El-Berri, ranti Fayokun, Sarah Galbraith-Emami, marta Guglielmetti, Per Hasvold, Benn mcGrady, Jeremias Paul, Leanne riley, Kate robertson, Susannah robinson, Stefan Savin, ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar Design by Estùdio infinito Layout by Jean-Claude Fattier Printed by WHO Document Production Services, Geneva, Switzerland . 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WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Printed in Switzerland Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe The Georgian parliament votes for a tobacco control bill, 2017. Plain packaging guidelines, Uruguay. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). As many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. An additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. At the same time, one country dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC Article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC Article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NATIONAl TOBACCO CONTrOl PrOgrAmmES PrOgrESS IN NATIONAl TOBACCO CONTrOl PrOgrAmmES (2008–2018) Decentralizing NTCP authority is important Adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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Geneva: World Health Organization; 2010 (http://www.who.int/tobacco/publica- tions/tax_administration/en, accessed 26 June 2019). 194. Petit P, Nagy J. Fiscal policy: how to design and enforce tobacco excises? Washington, DC; International monetary Fund; 2016 (https://www.imf.org/external/pubs/ft/how- tonotes/2016/howtonote1603.pdf, accessed 26 June 2019). 195. report on tobacco control in the region of the americas. Washington, DC: Pan american Health Organization; 2018 (http://iris.paho.org/ xmlui/handle/123456789/49237, accessed 26 June 2019). 196. reddy KS, yadav a, arora m, Nazar GP. Integrating tobacco control into health and development agendas. Tobacco Control. 2012;21:281–6. 197. David a, Esson K, Perucic a-m, Fitzpatrick C. Tobacco use: equity and social deter- minants. Geneva: World Health Organiza- tion; 2010. (http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some or many 3 appropriate characteristics 4 Or large warnings 5 missing many 6 appropriate characteristics 4 medium size warnings 2 with all appropriate characteristics 4 Or large warnings 5 missing some 3 appropriate characteristics 4 Large warnings 5 with all appropriate characteristics 4 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 5 average of front and back of the package is at least 50%. 6 Four or more. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 80.5% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Special thanks to Kelvin Khow Chuan Heng and vera Luiza da Costa e Silva from the World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of alexandra Choi and Pirathap Loganathan. administrative support was provided by: amal amoune-Naal, miriamjoy aryee-Quansah, Gareth Burns, rosane De Barros Serrao, Luis madge, Zahra ali Piazza, Ochid romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, rebecca röttger and anastasia vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by alison Commar, with support from Soothesuk Kusumpa and Elza anna Barzdina. The prevalence estimates were calculated by alison Commar, with the collaboration of ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, merideth Lewis-Cooney, alexandra Choi and Tuba asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba ayoub, annette m David, madmoud m Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, min Kyung Lim, Tim mcafee, Pratima murthy, yvonne Olando, Jennifer Percival, Olivier randriamahazosoa, martin raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana yunibhand. Other aspects of report were greatly enriched by inputs from Jorge alday, anna Gilmore, maciej Goniewicz, Brian King, Gan Quan. analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by anne-marie Perucic and robert Totanes with support from mark Goodchild, roberto Iglesias, Dora Nicolazzo and alejandro ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and adrienne Pizatella of the Bloomberg Initiative to reduce Tobacco use for their collaboration. Our thanks also go to Florence rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and alexey Kotov, as well as: Luiza amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, vaishakhi mallik, Irina morozova, Sandra mullin, Nandita murukutla, Nguyen Nhung, rebecca Perl, ancha rachfiansyah, Benjamin Gonzalez rubio, md. Nasir uddin and Winnie Chen yu. Special thanks also to the Campaign for Tobacco Free Kids, especially maria Carmona, Kaitlin Donley and monique muggli for their constructive exchange of tobacco control information and legislation. Thanks also to rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from alboum for the quality and speed with which we received the translations of legislation. vinayak Prasad, Douglas Bettcher and vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors aubra Godwin and angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-marie Dangou, Deowan mohee, Nivo ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco armada Perez, adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed mahfuzul Huq, Tara mona Kessaram, arvind rinkoo (Bangladesh), Kencho Wangdi (Bhutan), atul Dahal, Hye ran ri (DPr Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (maldives), myo Paing (myanmar), Lonim Dixit, md Khurshid alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: angela Ciobanu, Elizaveta Lebedeva, Kristina mauer-Stender. WHO Eastern Mediterranean Region: raouf alebshehy, Fatimah El-awa, Heba Fouad, miriam Gordon, radwa el Wakil. WHO Western Pacific Region: melanie aldeon, ramon de Guzman, mina Kashiwabara, Kate Lannan, Hai-rim Shin, Daravuth yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), ada moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic republic), Paul Soo, Narwant Kaur (malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (mongolia), anna maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi viki (Samoa), Kirsten Frandsen (Solomon Islands), yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (viet Nam). WHO Headquarters Geneva: virginia arnold, Ferranda Cotado, melanie Cowan, Hicham El-Berri, ranti Fayokun, Sarah Galbraith-Emami, marta Guglielmetti, Per Hasvold, Benn mcGrady, Jeremias Paul, Leanne riley, Kate robertson, Susannah robinson, Stefan Savin, ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar Design by Estùdio infinito Layout by Jean-Claude Fattier Printed by WHO Document Production Services, Geneva, Switzerland . The WHO report on the global tobacco epidemic, 2019 was made possible by funding from Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco ISBN 978 92 4 151282 4

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design by Estùdio infinito Layout by Jean-Claude Fattier Printed in Luxembourg Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, Turkey, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe Plain packaging guidelines, Uruguay. The Georgian parliament votes for a tobacco control bill, 2017. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). as many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. an additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. at the same time, one country dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NaTIONaL TOBaCCO CONTrOL PrOGrammES PrOGrESS IN NaTIONaL TOBaCCO CONTrOL PrOGrammES (2008–2018) Decentralizing nTCP authority is important adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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(http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some3 or many 4 appropriate characteristics5 Or large warnings 6 missing many 4 appropriate characteristics5 medium size warnings 2 with all appropriate characteristics5 Or large warnings6 missing some 3 appropriate characteristics 5 Large warnings 6 with all appropriate characteristics5 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 Four or more. 5 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 6 average of front and back of the package is at least 50%. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIII IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I IIII — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 80.5% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIIIII IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Special thanks to Kelvin Khow Chuan Heng and vera Luiza da Costa e Silva from the World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of alexandra Choi and Pirathap Loganathan. administrative support was provided by: amal amoune-Naal, miriamjoy aryee-Quansah, Gareth Burns, rosane De Barros Serrao, Luis madge, Zahra ali Piazza, Ochid romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, rebecca röttger and anastasia vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by alison Commar, with support from Soothesuk Kusumpa and Elza anna Barzdina. The prevalence estimates were calculated by alison Commar, with the collaboration of ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, merideth Lewis-Cooney, alexandra Choi and Tuba asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba ayoub, annette m David, madmoud m Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, min Kyung Lim, Tim mcafee, Pratima murthy, yvonne Olando, Jennifer Percival, Olivier randriamahazosoa, martin raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana yunibhand. Other aspects of report were greatly enriched by inputs from Jorge alday, anna Gilmore, maciej Goniewicz, Brian King, Gan Quan. analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by anne-marie Perucic and robert Totanes with support from mark Goodchild, roberto Iglesias, Dora Nicolazzo and alejandro ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and adrienne Pizatella of the Bloomberg Initiative to reduce Tobacco use for their collaboration. Our thanks also go to Florence rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and alexey Kotov, as well as: Luiza amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, vaishakhi mallik, Irina morozova, Sandra mullin, Nandita murukutla, Nguyen Nhung, rebecca Perl, ancha rachfiansyah, Benjamin Gonzalez rubio, md. Nasir uddin and Winnie Chen yu. Special thanks also to the Campaign for Tobacco Free Kids, especially maria Carmona, Kaitlin Donley and monique muggli for their constructive exchange of tobacco control information and legislation. Thanks also to rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from alboum for the quality and speed with which we received the translations of legislation. vinayak Prasad, Douglas Bettcher and vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors aubra Godwin and angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-marie Dangou, Deowan mohee, Nivo ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco armada Perez, adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed mahfuzul Huq, Tara mona Kessaram, arvind rinkoo (Bangladesh), Kencho Wangdi (Bhutan), atul Dahal, Hye ran ri (DPr Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (maldives), myo Paing (myanmar), Lonim Dixit, md Khurshid alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: angela Ciobanu, Elizaveta Lebedeva, Kristina mauer-Stender. WHO Eastern Mediterranean Region: raouf alebshehy, Fatimah El-awa, Heba Fouad, miriam Gordon, radwa el Wakil. WHO Western Pacific Region: melanie aldeon, ramon de Guzman, mina Kashiwabara, Kate Lannan, Hai-rim Shin, Daravuth yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), ada moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic republic), Paul Soo, Narwant Kaur (malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (mongolia), anna maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi viki (Samoa), Kirsten Frandsen (Solomon Islands), yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (viet Nam). WHO Headquarters Geneva: virginia arnold, Ferranda Cotado, melanie Cowan, Hicham El-Berri, ranti Fayokun, Sarah Galbraith-Emami, marta Guglielmetti, Per Hasvold, Benn mcGrady, Jeremias Paul, Leanne riley, Kate robertson, Susannah robinson, Stefan Savin, ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar The WHO report on the global tobacco epidemic, 2019 was made possible by funding from Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco ISBN 978 92 4 151282 4

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design by Estùdio infinito Layout by Jean-Claude Fattier Printed in Luxembourg Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, Turkey, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe Plain packaging guidelines, Uruguay. The Georgian parliament votes for a tobacco control bill, 2017. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). as many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. an additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. at the same time, one country dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NaTIONaL TOBaCCO CONTrOL PrOGrammES PrOGrESS IN NaTIONaL TOBaCCO CONTrOL PrOGrammES (2008–2018) Decentralizing nTCP authority is important adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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(http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some3 or many 4 appropriate characteristics5 Or large warnings 6 missing many 4 appropriate characteristics5 medium size warnings 2 with all appropriate characteristics5 Or large warnings6 missing some 3 appropriate characteristics 5 Large warnings 6 with all appropriate characteristics5 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 Four or more. 5 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 6 average of front and back of the package is at least 50%. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIII IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I IIII — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 80.5% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIIIII IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Special thanks to Kelvin Khow Chuan Heng and vera Luiza da Costa e Silva from the World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of alexandra Choi and Pirathap Loganathan. administrative support was provided by: amal amoune-Naal, miriamjoy aryee-Quansah, Gareth Burns, rosane De Barros Serrao, Luis madge, Zahra ali Piazza, Ochid romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, rebecca röttger and anastasia vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by alison Commar, with support from Soothesuk Kusumpa and Elza anna Barzdina. The prevalence estimates were calculated by alison Commar, with the collaboration of ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, merideth Lewis-Cooney, alexandra Choi and Tuba asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba ayoub, annette m David, madmoud m Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, min Kyung Lim, Tim mcafee, Pratima murthy, yvonne Olando, Jennifer Percival, Olivier randriamahazosoa, martin raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana yunibhand. Other aspects of report were greatly enriched by inputs from Jorge alday, anna Gilmore, maciej Goniewicz, Brian King, Gan Quan. analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by anne-marie Perucic and robert Totanes with support from mark Goodchild, roberto Iglesias, Dora Nicolazzo and alejandro ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and adrienne Pizatella of the Bloomberg Initiative to reduce Tobacco use for their collaboration. Our thanks also go to Florence rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and alexey Kotov, as well as: Luiza amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, vaishakhi mallik, Irina morozova, Sandra mullin, Nandita murukutla, Nguyen Nhung, rebecca Perl, ancha rachfiansyah, Benjamin Gonzalez rubio, md. Nasir uddin and Winnie Chen yu. Special thanks also to the Campaign for Tobacco Free Kids, especially maria Carmona, Kaitlin Donley and monique muggli for their constructive exchange of tobacco control information and legislation. Thanks also to rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from alboum for the quality and speed with which we received the translations of legislation. vinayak Prasad, Douglas Bettcher and vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors aubra Godwin and angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-marie Dangou, Deowan mohee, Nivo ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco armada Perez, adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed mahfuzul Huq, Tara mona Kessaram, arvind rinkoo (Bangladesh), Kencho Wangdi (Bhutan), atul Dahal, Hye ran ri (DPr Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (maldives), myo Paing (myanmar), Lonim Dixit, md Khurshid alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: angela Ciobanu, Elizaveta Lebedeva, Kristina mauer-Stender. WHO Eastern Mediterranean Region: raouf alebshehy, Fatimah El-awa, Heba Fouad, miriam Gordon, radwa el Wakil. WHO Western Pacific Region: melanie aldeon, ramon de Guzman, mina Kashiwabara, Kate Lannan, Hai-rim Shin, Daravuth yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), ada moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic republic), Paul Soo, Narwant Kaur (malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (mongolia), anna maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi viki (Samoa), Kirsten Frandsen (Solomon Islands), yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (viet Nam). WHO Headquarters Geneva: virginia arnold, Ferranda Cotado, melanie Cowan, Hicham El-Berri, ranti Fayokun, Sarah Galbraith-Emami, marta Guglielmetti, Per Hasvold, Benn mcGrady, Jeremias Paul, Leanne riley, Kate robertson, Susannah robinson, Stefan Savin, ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar The WHO report on the global tobacco epidemic, 2019 was made possible by funding from Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco ISBN 978 92 4 151282 4

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design by Estùdio infinito Layout by Jean-Claude Fattier Printed in Luxembourg Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, Turkey, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe Plain packaging guidelines, Uruguay. The Georgian parliament votes for a tobacco control bill, 2017. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). as many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. an additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. at the same time, one country dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NaTIONaL TOBaCCO CONTrOL PrOGrammES PrOGrESS IN NaTIONaL TOBaCCO CONTrOL PrOGrammES (2008–2018) Decentralizing nTCP authority is important adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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(http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some3 or many 4 appropriate characteristics5 Or large warnings 6 missing many 4 appropriate characteristics5 medium size warnings 2 with all appropriate characteristics5 Or large warnings6 missing some 3 appropriate characteristics 5 Large warnings 6 with all appropriate characteristics5 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 Four or more. 5 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 6 average of front and back of the package is at least 50%. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIII IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I IIII — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 80.5% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIIIII IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of Alexandra Choi and Pirathap Loganathan. Administrative support was provided by: Amal Amoune-Naal, Miriamjoy Aryee-Quansah, Gareth Burns, Rosane De Barros Serrao, Luis Madge, Zahra Ali Piazza, Ochid Romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and Marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, Rebecca Röttger and Anastasia Vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by Alison Commar, with support from Soothesuk Kusumpa and Elza Anna Barzdina. The prevalence estimates were calculated by Alison Commar, with the collaboration of Ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, Merideth Lewis-Cooney, Alexandra Choi and Tuba Asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba Ayoub, Annette M David, Madmoud M Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, Min Kyung Lim, Tim McAfee, Pratima Murthy, Yvonne Olando, Jennifer Percival, Olivier Randriamahazosoa, Martin Raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana Yunibhand. We also thank Katherine Deland for preparing the chapter ‘WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products’. Other aspects of report were greatly enriched by inputs from Jorge Alday, Anna Gilmore, Maciej Goniewicz, Brian King, Gan Quan. Analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by Anne-Marie Perucic and Robert Totanes with support from Mark Goodchild, Roberto Iglesias, Dora Nicolazzo and Alejandro Ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and Adrienne Pizatella of the Bloomberg Initiative to Reduce Tobacco Use for their collaboration. Our thanks also go to Florence Rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank Vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and Alexey Kotov, as well as: Luiza Amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, Vaishakhi Mallik, Irina Morozova, Sandra Mullin, Nandita Murukutla, Nguyen Nhung, Rebecca Perl, Ancha Rachfiansyah, Benjamin Gonzalez Rubio, Md. Nasir Uddin and Winnie Chen Yu. Special thanks also to the Campaign for Tobacco Free Kids, especially Maria Carmona, Kaitlin Donley and Monique Muggli for their constructive exchange of tobacco control information and legislation. Thanks also to Rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from Alboum for the quality and speed with which we received the translations of legislation. Vinayak Prasad, Douglas Bettcher and Vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors Aubra Godwin and Angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-Marie Dangou, Deowan Mohee, Nivo Ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco Armada Perez, Adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, Rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed Mahfuzul Huq, Tara Mona Kessaram, Arvind Rinkoo (Bangladesh), Kencho Wangdi (Bhutan), Atul Dahal, Hye Ran Ri (DPR Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (Maldives), Myo Paing (Myanmar), Lonim Dixit, Md Khurshid Alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, Renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: Angela Ciobanu, Elizaveta Lebedeva, Kristina Mauer-Stender. WHO Eastern Mediterranean Region: Raouf Alebshehy, Fatimah El-Awa, Heba Fouad, Miriam Gordon, Radwa el Wakil. WHO Western Pacific Region: Melanie Aldeon, Ramon de Guzman, Mina Kashiwabara, Kate Lannan, Hai-Rim Shin, Daravuth Yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), Ada Moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of Micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic Republic), Paul Soo, Narwant Kaur (Malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (Mongolia), Anna Maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi Viki (Samoa), Kirsten Frandsen (Solomon Islands), Yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (Vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (Viet Nam). WHO Headquarters Geneva: Virginia Arnold, Ferranda Cotado, Melanie Cowan, Hicham El-Berri, Ranti Fayokun, Sarah Galbraith-Emami, Marta Guglielmetti, Per Hasvold, Benn McGrady, Jeremias Paul, Leanne Riley, Kate Robertson, Susannah Robinson, Stefan Savin, Ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. Special thanks to Kelvin Khow Chuan Heng and Vera Luiza da Costa e Silva from the 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar The WHO report on the global tobacco epidemic, 2019 was made possible by funding from Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco ISBN 978 92 4 151282 4

WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use fresh and alive 2 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Chances of quitting tobacco can more than double with the right support. Quitting tobacco has major and immediate health benefits. . We will not reach global targets to reduce tobacco use and related deaths if we do not help people to quit now. WHO report on the global tobacco epidemic, 2019: Offer help to quit tobacco use is the seventh in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it. Monitor Protect Offer Warn Enforce Raise 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 Helping people to quit has more impact when efforts are combined with other tobacco control strategies. 10 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO Report on the Global Tobacco Epidemic, 2019 ISBN 978-92-4-151620-4 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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Design by Estùdio infinito Layout by Jean-Claude Fattier Printed in Luxembourg Made possible by funding from Bloomberg Philanthropies WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use CONTENTS 15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat 20 Summary 28 WHO FramEWOrK CONvENTION ON TOBaCCO CONTrOL aND THE PrOTOCOL TO ELImINaTE ILLICIT TraDE IN TOBaCCO PrODuCTS 36 OFFErING HELP TO QuIT TOBaCCO uSE 52 HEaTED TOBaCCO PrODuCTS 56 ELECTrONIC NICOTINE DELIvEry SySTEmS 60 TOBaCCO INDuSTry INTErFErENCE: THE GrEaTEST OBSTaCLE TO rEDuCING TOBaCCO uSE 68 EFFECTIvE TOBaCCO CONTrOL mEaSurES 70 Monitor tobacco use and prevention policies 76 Protect people from tobacco smoke 82 Offer help to quit tobacco use 90 Warn about the dangers of tobacco 96 Anti-tobacco mass media campaigns 100 Enforce bans on tobacco advertising, promotion and sponsorship 106 Raise taxes on tobacco 114 National tobacco control programmes: vital for ending the tobacco epidemic 118 CONCLuSION 120 rEFErENCES 128 TECHNICAL NOTE I: Evaluation of existing policies and compliance 134 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 136 TECHNICAL NOTE III: Tobacco taxes in WHO Member States 143 APPENDIX I: Regional summary of MPOWER measures 157 APPENDIX II: Tobacco dependence treatment 183 APPENDIX III: Year of highest level of achievement in selected tobacco control measures 197 APPENDIX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 203 APPENDIX V: Status of the WHO Framework Convention on Tobacco Control 209 aCKNOWLEDGEmENTS APPENDIX VI: Global tobacco control policy data APPENDIX VII: Country profiles APPENDIX VIII: Tobacco tax revenues APPENDIX IX: Tobacco taxes, prices and affordability APPENDIX X: Age-standardized prevalence estimates for tobacco use, 2017 APPENDIX XI: Country-provided prevalence data APPENDIX XII: Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/global_report/en 14 15WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 tobacco cessation interventions must be a priority for countries. at the same time, innovation is to be encouraged and mobile technologies should be fully harnessed to improve access to large and hard-to-reach populations. The importance of tobacco control and cessation for global health are reflected in the Sustainable Development Goals, which call for strengthened implementation of the WHO FCTC. The mPOWEr measures can assist governments by providing key tools to combat the global tobacco epidemic. Only if we help people quit tobacco now will we be able to reach our global targets to reduce the prevalence of tobacco use and avert years of debilitating illness and millions of preventable deaths. Dr Tedros Adhanom Ghebreyesus Director-General World Health Organization THE NuMBER Of PEOPLE PROTECTED By AT LEAsT ONE MPOWER MEAsuRE HAs MORE THAN QuADRuPLED sINCE 2007 “Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco.” Dr Tedros Adhanom Ghebreyesus, WHO Director-General “Tobacco control is a perfect example of what can be achieved in global health through global commitments.” Tobacco control is a perfect example of what can be achieved in global health through global commitments. Since the adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003, most countries have made great strides in implementing tobacco control measures. In 2008, WHO introduced the six mPOWEr measures to help countries implement the WHO FCTC using effective interventions that are proven to reduce demand for tobacco. Since the introduction of mPOWEr, the number of countries that have adopted at least one measure at best-practice level has more than quadrupled. We can now report that 136 countries covering 5 billion people have implemented at least one of the key policy interventions to reduce tobacco demand. more than ever, people are aware of tobacco’s harms and consequences. Due in part to these successes, many tobacco users now want to quit; and we know how to help them. This seventh WHO report on the global tobacco epidemic focuses on the “O” of mPOWEr: “Offer help to quit tobacco use”. Today’s tobacco users will make up the majority of future tobacco-related deaths, which will disproportionately affect low- and middle-income countries. Providing access to, and encouraging the use of, effective cessation interventions greatly increases the likelihood of successfully quitting tobacco. article 14 of the WHO FCTC calls for tobacco cessation services to be put in place at country level. recommended approaches include: brief advice at primary care level, national toll-free tobacco quit lines, cost-covered nicotine replacement therapies and the use of digital and mobile technologies to empower those who want to quit. These interventions work best in combination but can be introduced in a step-wise approach where resources are limited. Help to quit tobacco can and should be incorporated into any universal health coverage strategy. Over the past decade there has been a dramatic increase in middle-income countries incorporating partially or fully cost-covered quit interventions into some or most of their primary care services – population coverage rose from 16% in 2007 to 78% in 2018. among high-income countries, the rate has increased from 61% to 97%. Implementation of a full package of cessation services at best-practice levels however, remains remarkably uncommon in most countries. as of 2018 only 23 countries (including only six middle-income countries and one low-income country) offered comprehensive cessation support for tobacco users seeking help to quit. Governments must recognize this unmet need and act on it immediately as part of a comprehensive tobacco control strategy. Population-level, cost-effective 16 17WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and global support for effective policies is growing. But the fight against an aggressive and ever evolving industry is far from over. more national governments can focus greater attention on the scourge of tobacco. more can take strong, life- saving action. and together, by working to replicate proven strategies across the world, we can save millions more lives. Michael R. Bloomberg WHO Global ambassador for Noncommunicable Diseases and Injuries Founder, Bloomberg Philanthropies fIvE BILLION PEOPLE NOW COvERED By MPOWER POLICIEs sHOWING COuNTRIEs CAN WIN fIGHT AGAINsT THE TOBACCO EPIDEMIC “Together, by working to replicate proven strategies across the world, we can save millions more lives.” Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases Founder of Bloomberg Philanthropies Tobacco use poses an enormous threat to public health worldwide, killing more than eight million people every year. more countries are making tobacco control a priority and saving lives, but there is much more work to be done. The World Health Organization and Bloomberg Philanthropies are committed to accelerating the reduction of tobacco use worldwide. The challenges are daunting, but together, we are proving that this is a winnable fight. WHO tracks the implementation of the six mPOWEr strategies to reduce tobacco use, and by showing their impact we help spur more countries to adopt them. The mPOWEr measures, in line with the WHO Framework Convention on Tobacco Control, have helped countries make unprecedented progress. Since 2007, the share of the global population covered by at least one mPOWEr policy has more than quadrupled. The result is that today, five billion people are protected from the harmful effects of tobacco use, and the number of countries with best-practice cessation policies has more than doubled from 10 to 23. In addition to advice from primary care providers and toll-free quit lines, digital technology is transforming how people access cessation services and get help quitting. This report shines a spotlight on global efforts to help people quit tobacco, and it details some of our most important gains. India, for example, has greatly increased access to services through an innovative program that allows participants to enroll and receive tailored support to quit on their mobile phones. and Brazil is now the second country in the world that has passed all mPOWEr policies at the highest level. Noncommunicable diseases (NCDs) cause more than two thirds of deaths in developing countries, and tobacco use is a major risk factor for NCDs such as cancer and heart disease. yet, programs to reduce NCDs remain chronically underfunded. Only 2% of development funding goes toward their prevention. Bloomberg Philanthropies works in close partnership with Director-General Tedros Ghebreyesus and WHO to combat NCDs, “WHO tracks the implementation of the six MPOWER strategies to reduce tobacco use, and by showing their impact, we help spur more countries to adopt them.” 18 19WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TOBACCO CONTROL Is A KEy PART Of THE susTAINABLE DEvELOPMENT GOALs, MAKING sWIfT AND fuLL IMPLEMENTATION Of THE WHO fCTC MORE uRGENT THAN EvER Dr Vera Luiza da Costa e Silva Head of the WHO FCTC Secretariat “The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco.” “It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control.” Dr Vera Luiza da Costa e Silva, Head of the WHO FCTC Secretariat commitment to implementing the WHO FCTC. Published every 2 years since 2008, the WHO report on the global tobacco epidemic provides comparable data to enable analysis of progress towards protecting the world’s people from what is now globally the biggest single preventable cause of death. as this latest edition shows, there is much to applaud. already 5 billion people are now covered by at least one core demand reduction measure of the WHO FCTC at the highest level of achievement. and 136 countries now protect their populations by having one or more of these policies adopted at best-practice level (as defined in the report). However, while some Parties are making steady progress, many are lagging, and more needs to be done. It is no secret that the tobacco industry is our greatest obstacle to ending the tobacco epidemic. This industry makes vast profits from selling tobacco and making people dependent upon it – and they do not want anything to change. But for the sake of public health, and in the interests of our children and future generations, things must change. We are deeply concerned by the fact that the tobacco epidemic is shifting to the developing world, where less-well resourced countries find themselves unable to counter tobacco industry exploitation of new markets – often through blatant interference with public health policy-making. Implementing article 5.3 of the WHO FCTC, which requires Parties to protect public health policy from the tobacco industry, is a critical step to preventing tobacco industry interference in public health policy-making. This report focuses on tobacco cessation and outlines progress to date on the implementation of article 14 of the WHO FCTC. reducing demand for tobacco through cessation support is one of the WHO FCTC’s core demand reduction strategies. article 14 of the WHO FCTC and its Guidelines call upon Parties to implement a series of measures to assist tobacco users to quit. When countries implement such measures they could ensure, at the same time, that these interventions become integral parts of universal health coverage. The Convention Secretariat of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products welcomes the publication of the seventh WHO report on the global tobacco epidemic. The 181 Parties to the WHO FCTC have committed themselves to saving lives through tobacco control. Based on strong evidence, the WHO FCTC sets minimum standards to guide Parties in adopting strong tobacco control policies and legislation to tackle the tobacco epidemic, which causes 8 million deaths a year worldwide. The overarching objective of the treaty is to protect present and future generations from the devastating health, economic, social and environmental impact of tobacco. In the past year we have seen two major achievements in tobacco control. The first was the entering into force of the Protocol to Eliminate Illicit Trade in Tobacco Products on 25 September 2018. Fifty-five Parties to the WHO FCTC had already adhered to the Protocol by June 2019 – a sign of their deepening commitment to tackle the issue. The second major achievement was the adoption by the Conference of the Parties (COP, the governing body of the WHO FCTC) of the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 in October 2018. This strategy guides implementation of the WHO FCTC for the next 7 years, including the work of the Parties, the Convention Secretariat and other stakeholders, and serves as the basis for work planning and budgeting for the next three biennia. Since entering into force in 2005, the WHO FCTC has benefitted from the mandatory biannual Global progress report on implementation of the WHO Framework Convention on Tobacco Control, which reports on all provisions of the WHO FCTC. This report is submitted to every COP session and is published by the Convention Secretariat on its website. The last report, published in 2018, sets out Parties’ growing What this report further highlights is that cessation policies are still among the least implemented of all WHO FCTC demand reduction measures, with only 23 countries in total providing best-practice cessation services, the majority of which are high- income countries. Clearly there is room for greater action and the reason speaks for itself: if tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved. Successful case-studies for implementation of this article have also recently been documented by the Convention Secretariat in relation to comorbidities where tobacco use impacts on the diseases burden (e.g. tuberculosis and HIv/aIDS interventions as well as noncommunicable diseases). Today we have over a decade of experience and expertise in tackling tobacco use. Our role in promoting sustainable development is now recognized within the Sustainable Development Goals (SDGs) 2030 agenda, as Target 3a calls for strengthening the implementation of the WHO FCTC in all countries. It goes without saying that strong tobacco cessation support is needed to achieve the SDG targets on tobacco control. We welcome this new report for providing quality information and comparable data on progress in implementing selected demand reduction measures. Quitting tobacco has an immediate impact on health outcomes, and ensuring that strong cessation services are part of any tobacco control strategy will maximize the potential of these services to save lives. 20 21WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Summary place adding at least one more. This means a total of 36 countries introduced one or more mPOWEr measures at the highest level of achievement between 2016 and 2018. Tobacco cessation needs attention Offering help to quit – the focus of this seventh WHO report on the global tobacco epidemic – is an essential component of any tobacco control strategy. Global targets for reducing tobacco use will not be reached unless current tobacco users quit, and indeed, many tobacco users report that they want to quit. With the help of cost- effective population-based interventions, as outlined in the “O” measure of mPOWEr (Offer help to quit tobacco use), tobacco users greatly increase their chances of successfully quitting. unfortunately, only 13 new countries have started providing comprehensive cessation programmes since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007. However, in terms of population coverage, progress is still promising. One third of the world’s population – 2.4 billion people in 23 countries – have access to cessation services provided at best- practice level. This is 2 billion more people (26% of the world’s population) protected by comprehensive cessation support programmes since 2007, meaning that cessation programmes are now the second most adopted mPOWEr measure in terms of population coverage. This is thanks to two large countries, India and Brazil, adopting comprehensive cessation support at best-practice level. Significant progress has been made in low- and middle-income countries Of the 5 billion people protected by at least one complete mPOWEr measure, 3.9 billion live in low- and middle-income countries. Brazil and Turkey, the only two countries that have adopted all mPOWEr measures at the highest level, are both middle-income countries. In all, 61% of the population living in low- and middle- income countries are protected by at least one complete mPOWEr measure, and 44% are protected by at least two complete mPOWEr measures. There has been great improvement in low-income countries since 2007, when only three of the 34 countries in this income group had a single measure adopted. Today, half (17) of all low-income countries have at least one mPOWEr measure in place at best-practice level. There are now eight low-income countries that have one best-practice measure in place, five that have two, three (Chad, Nepal, Senegal) that have three and one (madagascar) that has four measures in place. Disappointingly, of the 17 low- income countries with no measures in place at best-practice level, only three run a tobacco control programme from their ministry of Health with at least five full- time equivalent staff. Progress in global tobacco control has been strong since mPOWEr was introduced in 2007 as a tool to help countries implement WHO FCTC demand reduction measures. Five billion people – about 65% of the world’s population – are now covered by at least one mPOWEr measure at the highest level of achievement. This number has more than quadrupled since 2007 when only 1 billion people – 15% of the world’s population – were protected by at least one mPOWEr measure (not including monitoring or mass media campaigns, which are assessed separately). Since the last WHO report on the global tobacco epidemic, two years ago, progress has been steady, with 15 countries that previously had no best-practice measures taking action to reach best-practice level on one or more measures, and a further 21 countries that had at least one measure in SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2018 W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Sh ar e of w or ld p op ul at io n 22% P Smoke-free environments 32% O Cessation programmes 52% Pack warnings 24% Mass media E Advertising bans 18% 14% R Taxation M Monitoring 38% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories refer to Technical Note I. Five billion people – about 65% of the world’s population – are now covered by at least one MPOWER measure at the highest level of achievement. 22 23WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Countries in all regions are adopting new measures Each mPOWEr measure has been adopted at best-practice level by new countries since the last report: n Seven countries (antigua and Barbuda, Benin, Burundi, Gambia, Guyana, Niue and Tajikistan) newly adopted complete smoke-free laws covering all indoor public places and workplaces. n Four countries (Czechia, Saudi arabia, Slovakia and Sweden) advanced to best-practice level with their tobacco use cessation services. However, during the same time period, six other countries dropped from the highest group, resulting in a net loss of two countries. aT LEaST TWO mPOWEr POLICIES aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 Po pu la ti on p ro te ct ed (b ill io ns ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Total population: 7.6 billion Total number of countries: 195 Population (billions) Countries 11 15 26 37 46 70 82 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 n Fourteen countries (Barbados, Cameroon, Croatia, Cyprus, Georgia, Guyana, Honduras, Luxembourg, Pakistan, Saint Lucia, Saudi arabia, Slovenia, Spain and Timor-Leste) adopted large graphic pack warnings, including plain packaging for Saudi arabia. n Ten countries (antigua and Barbuda, azerbaijan, Benin, Congo, Democratic republic of the Congo, Gambia, Guyana, Niue, Saudi arabia and Slovenia) introduced comprehensive bans on tobacco advertising, promotion and sponsorship (TaPS), including at point-of-sale. n Ten countries (andorra, australia, Brazil, Colombia, Egypt, mauritius, montenegro, New Zealand, North macedonia and Thailand) moved to the top group for taxes so that they comprise at least 75% of retail prices. Over half of the world’s population – 3.9 billion people living in 91 countries – benefit from large graphic pack warnings featuring all recommended characteristics, making it the mPOWEr measure with both the highest population coverage and the most countries covered. It is also important to note that by the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). Plain packaging legislation is also in progress in at least nine other countries. There are 1.6 billion people living in the 62 countries that have completely banned smoking in public places and workplaces, making this the second most realised mPOWEr measure in terms of country adoption. aT LEaST ONE mPOWEr POLICy aT HIGHEST LEvEL OF aCHIEvEmENT (2007–2018) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) Total population: 7.6 billion Total number of countries: 195 75 55 43 92 106 121 136 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Population (billions) Countries THE STaTE OF SELECTED TOBaCCO CONTrOL POLICIES IN THE WOrLD, 2018 P Smoke-free environments O Cessation programmes Pack warnings W Mass media E Advertising bans R Taxation 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) Data not reported/ not categorized No policy or weak policy Minimal policies Moderate policies Complete policies 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Monitoring 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data, or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 59 35 74 27 100% Note: Bhutan and Brunei Darussalam are excluded from r because sale of cigarettes is banned. refer to Technical Note I for category definitions. 24 25WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2016 TO 2018 Sh ar e of w or ld p op ul at io n E Advertising bans R Taxation O Cessation programmes Pack warnings W 48% 4% Mass media 2018 2016 P Smoke-free environments M Monitoring 2%42% -4% * 0% -1% * -21% * Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level; for the definitions of these highest categories, refer to Technical Note I. * The share of the world's population covered by this measure decreased since 2016. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% INCrEaSE IN THE SHarE OF THE WOrLD POPuLaTION COvErED By SELECTED TOBaCCO CONTrOL POLICIES, 2007* TO 2018 Sh ar e of w or ld p op ul at io n R Taxation E Advertising bans O Cessation programmes W 4% 2018 2007 P Smoke-free environments M Monitoring 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Note: The tobacco control policies depicted here correspond to the highest level of achievement at the national level. * Mass media coverage refers to 2010, not 2007. Taxation coverage refers to 2008, not 2007. #The population covered by mass media campaigns decreased since 2010. Pack warnings Mass media -10%# 33% While only 38 countries levy taxes as high as the WHO-recommended 75% of the retail price of a pack of cigarettes, another 62 countries levy taxes comprising between 50% and 75% of the price, and a further 61 levy taxes between 25% and 50%. Essentially, these countries are well-positioned to further raise taxes as tobacco taxation gains more widespread support. The population covered by protective measures is growing Since 2016, 14 new countries have adopted large graphic warning laws at best-practice level, making it the most adopted mPOWEr measure over the last 2 years. advertising bans also saw double- digit growth at best-practice level, with 10 additional countries adopting complete TaPS bans. Two mPOWEr measures – creating smoke-free environments and raising taxes – saw seven countries begin covering their population at best-practice level. The greatest growth in population coverage since 2016 was seen in taxation. The population coverage from this mPOWEr measure has almost doubled from 8% in 2016 to 14% in 2018. Even so, taxation, although the most effective way to reduce tobacco use, is still the mPOWEr measure with the lowest population coverage. The population covered by pack warnings increased by 4%, and the population covered by advertising bans increased by 2%. although seven countries advanced their smoke-free environment laws to best- practice levels, the population coverage did not change visibly because the countries were not populous. The population covered by measures on monitoring tobacco use and prevention policies, Cessation programmes and mass media campaigns have all decreased since 2016. Coverage of cessation programmes declined by 1% owing to the net loss of two countries from the best-practice group. The decline in monitoring coverage is most likely not a true decline, as it typically takes 1–3 years for surveys to Incomplete or partial policies are a stepping stone to complete policies Even where best-practice levels have not yet been achieved, each of the mPOWEr measures has received some level of attention in the majority of the world’s countries. In addition to the 62 countries with a complete law on smoke-free environments, 70 countries have minimal to moderate laws that ban smoking in some but not all public spaces and workplaces, laying the groundwork for establishing a fully effective law in the future. This means that although the partial bans do not currently effectively protect these populations from the harms of second-hand smoke, growing public support will mean that, for most countries, only amendments to the law will be needed in some of these countries, whereas the adoption of a new law will be necessary in others. While only 23 countries have cessation support policies that meet the criteria for best-practice adoption, there are an additional 116 countries that provide fully or partially cost-covered services in health facilities, and 32 more that provide services but do not provide cost-coverage for them. This makes a total of 171 countries in which tobacco users wanting to quit can find some level of support. In addition to the 91 countries that mandate strong graphic health warnings on cigarette packs, 61 other countries have minimal to moderate laws that require some kind of warning on packs. These less-prominent warnings, while not as effective as the best-practice warnings, show some effort is being made to communicate the dangers of tobacco use to consumers, and provide an avenue for these 61 countries to strengthen their mandated warnings to best-practice level in the future. In addition to the 48 countries that have adopted a TaPS ban, another 103 countries have partial TaPS bans in place, so at least some forms of advertising, promotion and sponsorship are already illegal – and once the principle of a ban is established and accepted, it becomes easier to extend it to best-practice level. 26 27WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 be published after fieldwork is completed and only then will they be reported here. Some surveys that were conducted in 2017 and 2018 therefore will not be captured until the next WHO report on the global tobacco epidemic in 2021. The 21% decline in the population coverage of mass media campaigns is concerning, since the maintenance of regular mass media campaigns is crucial to keeping the conversation open with the public about the harms of tobacco and the need for tobacco control efforts to continue. It is inspiring that 91 countries have large graphic warning requirements, making it the most adopted measure to date. more countries have adopted the graphic warning requirement since mPOWEr began than any other measure, with 82 additional countries now covered at best- practice level, up from just nine in 2007. It is followed by the adoption of smoke-free requirements in public and workplaces, which has 52 additional countries at best- practice level, up from just 10 in 2007, and advertising, promotion and sponsorship bans, adopted by an additional 41 countries, up from just 7 in 2007. Some countries have yet to adopt a single MPOWER measure all countries have the ability to implement strong tobacco control policies to protect their populations from tobacco use and second-hand smoke exposure, and the illness, disability and death that they cause. although the adoption of comprehensive tobacco control policies has advanced steadily since 2007, there is much work to be done. There are 59 countries that have yet to adopt a single mPOWEr measure at the highest level of achievement – and 49 of them are low- and middle-income countries. additionally, the pace of progress for adopting some mPOWEr measures has been slower than for others. For example, the adoption of complete TaPS bans and the raising of tobacco taxes to sufficiently high levels is much too slow in the majority of countries. There are 59 countries that have yet to adopt a single MPOWER measure at the highest level of achievement. 28 29WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. In may 2003, WHO member States made history by adopting the WHO Framework Convention on Tobacco Control (WHO FCTC) (1) – the first modern treaty specifically related to public health. Today 181 parties are signatories to the WHO FCTC, enabling it to cover more than 90% of the global population. It is one of the most widely adopted united Nations instruments. In negotiating the WHO FCTC, countries took a brave and forward-looking stand against an industry that, as admitted in its own internal documents, manufactures addictive, deadly products in the pursuit of profit. For decades the industry has targeted the most vulnerable people – women, children, and those on low incomes – with sophisticated advertising campaigns to ensure they capture the full market. They have also manipulated their product design to maximize addictiveness. The WHO FCTC has also established a forum for discussions to address new challenges as they emerge, for example the promotion in new markets of tobacco products from traditional cultures such as narghiles and smokeless tobacco, and hundreds of categories and brands of novel products such as electronic nicotine delivery systems and heated tobacco. These new challenges point to the need for further regulation. By ratifying the WHO FCTC, countries have firmly articulated their commitment to curbing the tobacco epidemic. as strong as the WHO FCTC is, its Parties recognize that there are aspects of tobacco control that need highly tailored responses. One of these areas is the illicit (often cross- border) trade in tobacco products. This trade poses a serious threat to public health because it undermines strong measures such as pictorial health warnings and increases access to often cheaper tobacco products, thus fueling the tobacco epidemic and undermining tobacco control policies. It also causes substantial losses in government revenues, and at the same time contributes to the funding of international criminal activities. This matter is so serious that the Parties to the Convention negotiated a new international treaty that complements the WHO FCTC. The Protocol to Eliminate Illicit Trade in Tobacco Products The Protocol to Eliminate Illicit Trade in Tobacco Products (2) is the first protocol to the WHO FCTC. The Protocol was adopted by consensus of the Fifth Session of the Conference of the Parties in 2012 and currently has 55 Parties. as a legally binding instrument, the Protocol sets out binding legal obligations in much the same way as the WHO FCTC itself. The Protocol aims at eliminating all forms of illicit trade in tobacco products. It provides tools for preventing illicit trade by securing the supply chain, including licensing and establishing an international tracking and tracing system for tobacco products and countering illicit trade through dissuasive law enforcement measures and a suite of actions to enable international cooperation. This new treaty in its own right entered into force in 2018. The first session of the meeting of the Parties (mOP1) to the Protocol was held in Geneva, just after its entering into force (3, 4). reflecting the WHO FCTC itself, the Protocol has 10 parts. It contains an introduction and general obligations (Parts I and II), substantive parts comprising supply chain control, offences and international cooperation (Parts III, Iv and v), and reporting (Part vI). Parts vII, vIII, IX and X cover institutional arrangements, settlement of disputes, development of the Protocol and final provisions. Examples of the topics addressed in the 47 provisions of the Protocol include licensing or an equivalent approval or control system (article 6); tracking and tracing (article 8); duty free sales (article 12); unlawful conduct including criminal offences (article 14); assistance and cooperation including mutual administrative (article 28) and mutual legal assistance (article 29). Parts of the WHO Framework Convention on Tobacco Control The WHO FCTC is unique among framework conventions in the depth and breadth of the substantive obligations it contains on both the demand and supply sides. Demand reduction n article 6. Price and tax measures to reduce the demand for tobacco n article 7. Non-price measures to reduce the demand for tobacco n article 8. Protection from exposure to tobacco smoke n article 9. regulation of the contents of tobacco products Global Progress in the WHO Framework Convention on Tobacco Control (WHO FCTC) (5) 30 31WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n article 10. regulation of tobacco product disclosures n article 11. Packaging and labelling of tobacco products n article 12. Education, communication, training and public awareness n article 13. Tobacco advertising, promotion and sponsorship n article 14. Demand reduction measures concerning tobacco dependence and cessation Supply reduction n article 15. Illicit trade in tobacco products n article 16. Sales to and by minors n article 17. Provision of support for economically viable alternative activities as part of its general obligations, the WHO FCTC obliges Parties to protect their policy-making and implementation from the influence of tobacco interests (article 5.3). With this inclusion, the WHO FCTC addresses the full chain of tobacco product production, distribution and sale. Parties have also adopted, by consensus, guidelines for implementation of key provisions of the WHO FCTC, which help them meet their legal obligations through recommended actions that elaborate on the provisions. They were developed through intergovernmental processes and adopted by the Parties at different sessions of the COP. Governance of the WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products The WHO FCTC’s governing body is the Conference of the Parties (COP) and it comprises all 181 Parties. Similarly, the meeting of the Parties (mOP) provides governance for the Protocol to Eliminate Illicit Trade in Tobacco Products and includes all Parties to the Protocol. Both bodies meet every 2 years, with the last sessions taking place in late 2018. The work of the COP and mOP is governed by their respective rules of Procedure (3, 4) and keeps under regular review the implementation of the WHO FCTC and the Protocol, and takes decisions necessary to promote their effective execution, including the establishment of subsidiary bodies such as working groups and expert groups (6). Focused on their respective instruments, the COP and the mOP monitor implementation progress, identify challenges and opportunities, and review ongoing business. Housed at WHO headquarters, the Convention Secretariat supports the Parties to both treaties, working closely with WHO and the observers to ensure complementarity and synergy. Article 14 – Demand reduction measures concerning tobacco dependence and cessation The WHO FCTC directly speaks to the importance of reducing the number of current tobacco users through cessation measures in article 14 – Demand reduction measures concerning tobacco dependence and cessation (7). This article states: 1. Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2. Towards this end, each Party shall endeavour to: (a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments; (b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; (c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and (d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate. although article 14 is the only article dedicated to cessation, a number of provisions in the WHO FCTC refer indirectly to cessation – for instance, all demand reduction measures will implicitly impact cessation. additionally, article 12, Education, communication, training and public awareness, includes a number of references to raising awareness of the dangers of tobacco use across sectors and the health benefits of cessation. This includes a direct reference in paragraph (b), which commits each Party to adopt and implement effective legislative, executive, administrative or other measures to promote “public awareness about the health risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles as specified in article 14.2”(8). Article 14 of the WHO FCTC speaks directly to the importance of reducing the number of current tobacco users through cessation measures. 32 33WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The 2018 Global progress report on implementation of the WHO Framework Convention on Tobacco Control: a report based on information from the WHO FCTC reporting system Based on the implementation reports of the Parties submitted to the Conference of the Parties in accordance with article 21 of the Convention, the Convention Secretariat regularly prepares biennial global progress reports. The 2018 Global progress report was launched at COP8 (9). Guidelines for implementation of Article 14 of the Convention adopted by COP4 in 2010 as decision FCTC/COP4(8), Guidelines for Implementation of article 14 are intended to “assist Parties in meeting their obligations under article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities”. To this end, the guidelines: (i) encourage Parties to strengthen or create a sustainable infrastructure that motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available; (ii) identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health care systems; and (iii) urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment. as the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. The principles that Parties should follow when integrating cessation into their health systems include: n recognizing that tobacco use is highly addictive n Tobacco dependence treatment measures should be implemented synergistically with other tobacco control measures n Tobacco cessation and tobacco dependence treatment strategies should be based on the best available evidence of effectiveness n Treatment should be accessible and affordable n Tobacco cessation and tobacco dependence treatment should be inclusive n monitoring and evaluation are essential n active partnership with civil society n Development and implementation of tobacco control cessation policies should be protected from all commercial and vested interests n Sharing experiences among Parties greatly enhances Parties’ abilities to implement the guidelines n Strengthening existing health care systems to promote tobacco cessation and tobacco dependence treatment is essential. In addition to a set of defined terms, each substantive section of the Guidelines includes recommendations to assist Parties in their implementation of article 14 of the Convention. The key recommendations are the following: Developing an infrastructure to support tobacco cessation and treatment of tobacco dependence Suggested actions include conducting a national situation analysis; creating or strengthening national coordination; developing and disseminating comprehensive guidelines; addressing tobacco use by health care workers and others involved in tobacco cessation; developing training capacity; using existing systems and resources to ensure the greatest possible access to services; making the recording of tobacco use in medical notes mandatory; encouraging collaborative working; and establishing a sustainable source of funding for cessation help. Key components of a system to help tobacco users quit It is recommended that cessation support and treatment is provided in all health care settings and by all health care providers. Providing cessation support and treatment in non-health care settings and by suitably trained non-health care providers should also be considered, especially where scientific evidence suggests that some groups of tobacco users may be better served in this way. actions for Parties include establishing population-level approaches; establishing more intensive individual approaches; making medications available; and considering emerging research evidence, novel approaches, and mass media. Developing cessation support: a stepwise approach Guidelines recommend that Parties should implement measures to promote tobacco cessation and increase demand for tobacco dependence treatment contained in other articles of the WHO FCTC. They should also use existing infrastructure, in both health care and other settings, to ensure that all tobacco users are identified and provided with at least brief advice. actions to achieve this include creating an infrastructure and environment that prompts quit attempts by establishing health system components that support cessation (including through adequate funding and training); addressing cessation among health care workers themselves; and integrating brief advice into existing health care systems. Monitoring and evaluation The Guidelines recommend that Parties monitor and evaluate all tobacco cessation and tobacco dependence treatment strategies and programmes, including process and outcome measures, to observe trends. additionally, Parties should benefit from the experience of other countries through the exchange of information. To ensure that robust monitoring and evaluation takes place, Parties should formulate measurable objectives, determine the resources required, and identify indicators to enable the assessment of progress towards each objective. additionally, they should encourage health care workers and service providers to participate in the monitoring of service performance through clearly defined indicators, taking account of national circumstances and priorities. Lastly, Parties should use data collection systems that are practical and efficient, built on strong methodologies, and appropriate to local circumstances. International cooperation The Guidelines recommend that Parties collaborate internationally to ensure that they are able to implement the most effective tobacco cessation measures. To this end, Parties should share their tobacco cessation and treatment experiences with other Parties, including strategies to develop and fund support for cessation of tobacco use, national treatment guidelines, training strategies, and data and reports from evaluations of tobacco dependence treatment systems. Where appropriate, it is suggested that Parties use international reporting mechanisms such as regular reporting on the implementation of the WHO FCTC and take advantage of bilateral and multilateral contacts and agreements. Finally, Parties should review and revise these guidelines periodically to ensure they continue to provide effective guidance and assistance. Guidelines for implementation of Article 14. As the foundation for the guidelines, the Parties drafted a set of underlying considerations for implementing cessation programmes. 34 35WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 FCTC 2030 Through a development assistance project called FCTC 2030 (10), the Convention Secretariat is supporting 15 low- and middle-income countries to strengthen implementation of the WHO FCTC by integrating tobacco control with other health and development activities. many of the FCTC 2030 countries are working to develop and implement tobacco cessation programmes in line with article 14 of the WHO FCTC and the Convention Secretariat has been working with the governments of FCTC 2030 countries to promote the integration of tobacco cessation into primary health and care systems. Examples of outcomes of the project include the development of an online course on tobacco cessation in Colombia and the provision of Trainings of Trainers to health professionals in all seven provinces in Nepal. Through FCTC 2030, the Convention Secretariat has also partnered with the united Nations Development Programme (uNDP) to develop an Issue Brief that aims to build awareness of the options to incorporate tobacco cessation activities into grants from The Global Fund to Fight aIDS, Tuberculosis and malaria (11). The document outlines how tobacco consumption worsens tuberculosis and HIv outcomes, and how the integration of tobacco control into these grants could increase health benefits and efficiencies. Group activity as part of the El Salvador cessation programme of the ‘addiction Prevention and Treatment Centers’ Global commitment to the WHO FCTC Each of the outcome documents of the three High-level meetings held by the united Nations’ General assembly (uNGa) on noncommunicable diseases has endorsed and encouraged countries to implement the WHO FCTC. The same approach was taken by uN member States when adopting the Sustainable Development Goals (SDG) agenda, streamlining through uNGa the implementation of the WHO FCTC through Target 3a: to “strengthen the implementation of the WHO FCTC in all countries, as appropriate”. additionally, the Eighth Conference of the Parties to the WHO FCTC adopted the Global Strategy to accelerate Tobacco Control: advancing Sustainable Development through the Implementation of the WHO FCTC 2019–2025 (12). Target 3.4 By 2030, reduce by one third premature mortality from NCDs Target 3A Strengthen the implementation of the WHO FCTC 36 37WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offering help to quit tobacco use Cessation support can more than double the chance of successfully quitting four cigarettes, and after smoking five packs, nearly 60% are dependent (18). most people who use tobacco regularly do so because they are addicted to nicotine and can therefore benefit greatly from a range of effective tobacco cessation interventions. For example, the highest- level cessation policies, adopted in 14 countries from 2007 to 2014, will result in about 1.5 million fewer future tobacco- related deaths up to the year 2030 (19). The health benefits of quitting tobacco are immediate People start to reap the health benefits within hours or even minutes of quitting tobacco use. In the course of just a day, quitting tobacco can be expected to help reduce a person’s heart rate and blood pressure, and blood carbon monoxide levels can be expected to return to normal (20). Within 3 months of quitting smoking, the circulation and lung function of a quitter improves. Coughing and shortness of breath will generally decrease within 1–9 months of quitting smoking (20). The risk of death due to tobacco use also begins to decrease soon after quitting. Current evidence suggests that the risk of death due to ischemic heart disease is halved within 5 years of quitting, and the risk of stroke returns to that of a never smoker within 5–15 years. Even the risk of death due to lung cancer is reduced by 30–50% within 10 years of quitting smoking (20). The success of tobacco control policies has increased demand for support to quit tobacco use. Tobacco cessation support should be made readily accessible in order to have a greater impact on reducing the prevalence of tobacco use. Many tobacco users want to quit and need help to quit There are 1.1 billion adult smokers globally and at least 367 million smokeless tobacco users (13), many of whom say they want – or intend – to quit (14, 15). While this is encouraging, tobacco cessation support worldwide remains low and many people do not have adequate cessation support available to them. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). Over the past decade, countries have made substantial progress in establishing evidence-based and cost-effective tobacco control measures. In numerous countries, many indoor public spaces are now smoke-free, warnings of the dangers of tobacco use appear on packaging and mass media messages, higher tobacco product prices and taxes have reduced the affordability of tobacco products, and tobacco product advertising, promotion and sponsorship have been prohibited. all of these efforts have contributed to reduced demand for tobacco products and increased existing tobacco users’ intention to quit. On average, across countries where the Global adult Tobacco Survey HOW QuITTING TOBaCCO HELPS yOur BODy (20–25) Source: Global adult Tobacco Survey (14) a Proportions include those who indicated they were thinking of quitting in the next month, within the next 12 months or sometime in the future. has been conducted, over 60% of smokers indicated that they intend to quit, and over 40% had attempted to quit in the 12 months preceding the survey. Tobacco cessation support services complement countries’ tobacco control measures and can contribute to reducing the prevalence of tobacco use. Cessation support helps tobacco users to quit Nicotine, a pharmacologically active drug that naturally occurs in the tobacco plant, is highly addictive and delivered rapidly to the brain following inhalation or ingestion of tobacco products, or the use of non-tobacco products that contain nicotine (17). Nicotine is so addictive that the autonomy of a quarter of teens starts to diminish after smoking just three or There are immediate and long-term health benefits in quitting for all tobacco users Within 20 minutes the heart rate and blood pressure drop (22). Within 12 hours the carbon monoxide level in the blood drops to normal (23). 2–12 weeks after quitting tobacco use the circulation improves and lung function increases (20). 6 weeks after quitting smokeless tobacco use 97% of oral leukoplastic lesions are completely resolved (24). 1–9 months after quitting smoking coughing and shortness of breath decrease (20). 1 year after quitting smoking the risk of coronary heart disease is about half that of a smoker (20). 1–4 years after quitting smokeless tobacco use the risk of death falls to nearly half that of a person who continues to use it (25). 5–15 years after quitting smoking the risk of death due to ischemic heart disease is halved the risk of stroke is reduced to that of a non-smoker (20). 10 years after quitting smoking the risk of lung cancer falls to about half that a of a smoker, and the risk of cancer of the mouth, throat, oesophagus, bladder, cervix and pancreas decreases (20). 15 years after quitting smoking the risk of coronary heart disease is that of a person who never smoked (20). PrOPOrTION OF CurrENT SmOKErS WHO INTEND TO QuIT (COuNTrIES WITH GLOBaL aDuLT TOBaCCO SurvEy DaTa, varIOuS yEarS)a Pakistan 2014 China 2010 Egypt 2009 Indonesia 2011 India 2017 Poland 2010 Brazil 2008 Greece 2013 Viet Nam 2015 Thailand 2011 Turkey 2012 Russian Federation 2016 Philippines 2015 Romania 2011 Uganda 2013 Kazakhstan 2014 Panama 2013 Bangladesh 2017 Cameroon 2013 Nigeria 2012 Qatar 2013 Ethiopia 2016 Ukraine 2017 Malaysia 2011 Uruguay 2017 Costa Rica 2015 Argentina 2012 Kenya 2014 Mexico 2015 Senegal 2015 Botswana 2017 0 10 20 30 40 50 60 70 80 90 38 39WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Strong cessation services save lives, improve health and save money People who quit tobacco can live longer, healthier and more productive lives. Quitting smoking at any time in life is likely to extend life expectancy – for example, quitting as a 30-year-old can add up to 10 years of life expectancy. Even at the age of 50 years, quitting results in an average of 6 years of life expectancy gained (21). In other words, it is never too late to gain the health benefits from quitting tobacco use. Life years gained can also be expected to be lived in better health, as the diseases caused by tobacco use are commonly chronic and debilitating, and lead to years of diminished quality of life. Quitting can therefore reduce the health care costs associated with long-term illness while also increasing the years of economically and socially productive lives. Increasing the number of people who quit tobacco will also benefit economies. In 2012, health care expenditures due to smoking-attributable diseases totaled uS$ 422 billion globally. If loss of productivity due to smoking-attributable illnesses and deaths are taken into account, this cost is estimated to be as high as uS$ 1436 billion, with almost 40% of these costs incurred in low- and middle-income countries (26). Therefore, reducing tobacco consumption through the implementation of comprehensive tobacco control measures – including offering help to quit – can ensure large savings for countries as well as for ex-tobacco users. In one Danish study, the estimated total lifetime health cost savings to society of a moderate smoker quitting at the age of 35 was €24 800 for men and €34 100 for women (27). Supporting tobacco users to quit is embedded in the global health agenda Following the Political Declaration on noncommunicable diseases adopted by the uN General assembly in 2011, WHO developed nine voluntary global targets to reduce global mortality from the four main noncommunicable diseases (NCDs) – cardiovascular diseases, cancer, chronic lung diseases and diabetes – and accelerate action against the leading risk factors for NCDs. The agreed target for tobacco control is a 30% relative reduction in the prevalence of current (daily and occasional) tobacco use in persons aged 15 years and above between 2010 and 2025, which was endorsed by the World Health assembly in may 2013. To achieve this target, it is not only essential to prevent the uptake of tobacco, but also to ensure that more tobacco users quit. Today, a number of highly effective and inexpensive interventions exist to help make this happen. The importance of helping current tobacco users quit is reflected in the WHO Global action Plan for the Prevention and Control of NCDs 2013–2020 (28). The Global action Plan lists a menu of “best-buys” and cost-effective policy options for countries to address the NCD burden. These include the recommendation that countries should “provide cost-covered, effective and population-wide cessation support (including brief advice, national toll-free quit line services and mCessation) to all those who want to quit” (28). The Sustainable Development Goals (SDGs) reinforce the need for all countries to act decisively to reduce tobacco use by calling for – as a specific target under SDG 3 on good health and well-being – the strengthening of WHO Framework Convention on Tobacco Control (FCTC) implementation globally. article 14 of the WHO FCTC clarifies both the need for, and the means to achieve, implementation of tobacco cessation policies and cost- covered services. Despite these commitments, progress towards best-practice cessation support in countries is slow compared to progress on other mPOWEr measures (such as smoke-free places, and bans on tobacco advertising, promotion and sponsorship). Effective cessation interventions are available There is a wide choice of behavioural and pharmacological tobacco cessation interventions Without cessation assistance, 4% of attempts to quit tobacco succeed (29). Proven cessation medications and professional support can double a tobacco user’s chance of successfully quitting (30). a number of different approaches have been developed to help people stop using tobacco. These range in terms of intensity, cost and effectiveness, and can broadly be categorized as behavioural or pharmacological interventions. Behavioural interventions While behavioural interventions for tobacco cessation are generally low cost, they can be very effective. Brief advice from health professionals as part of their routine consultations or interactions is an approach that makes use of existing health care systems. When a tobacco user visits a primary or specialized care service it presents an opportunity for the health care worker to offer and provide them with personalized counselling. Brief advice is a key means of motivating people who might not otherwise seek tobacco cessation Population-level approaches Brief advice Advice to stop using tobacco, usually taking only a few minutes, is given to all tobacco users during the course of a routine consultation and/or interaction with a physician or health care worker. Quit lines A national toll-free quit line is a telephone counselling service that can provide both proactive and reactive counselling. A reactive quit line provides an immediate response to a call initiated by the tobacco user, but only responds to incoming calls. A proactive quit line involves setting up a schedule of follow-up calls to tobacco users to provide ongoing support. mTobacco cessation Tobacco cessation interventions are delivered via mobile phone text messaging. Mobile technologies provide the opportunity to expand access to a wider population, and text messaging can provide personalized tobacco cessation support in an efficient and cost- effective manner. Individual specialist approaches Intensive behavioural support Behaviour support refers to multiple sessions of individual or group counselling aimed at helping people stop their tobacco use. It includes all cessation assistance that imparts knowledge about tobacco use and quitting, and provides support and resources to develop skills and strategies for changing behaviour. Cessation clinics In many countries, clinics specializing in tobacco cessation services are available. These clinics offer intensive behavioural support, and where appropriate, medications or advice on the provision of medications, delivered by specially trained practitioners. NRTs are available in several forms including gum, lozenges, patches, inhalers and nasal spray. These cessation tools reduce craving and withdrawal symptoms by providing a low, controlled dose of nicotine without the toxins found in cigarettes. The doses of NRT are gradually reduced over time to help the tobacco user wean off nicotine by getting used to less and less stimulation. These include medications such as bupropion, varenicline and cytisine. These pharmacotherapies reduce cravings and withdrawal symptoms and decrease the pleasurable effects of cigarettes and other tobacco products. TyPES OF TOBaCCO CESSaTION INTErvENTIONS BE H AV IO u RA L In TE RV En TI O n S PH A RM A CO LO G IC A L In TE RV En TI O n S support and encouraging them to quit, and as such is an essential component of tobacco cessation services. Countries can easily train physicians and health care workers to provide brief advice effectively to the population they serve. Toll-free quit lines are a convenient way for tobacco users who are ready to quit to access brief and potentially intensive behavioural counselling. Those that use quit lines increase their absolute quit rate by 4 percentage points, which represents a doubling of success compared to those who attempt to quit without assistance (30). This rate can be further increased if the quit line is “proactive” and counsellors make follow- up calls to potential tobacco quitters. With the advent and spread of mobile phone technologies, people who want to quit can now be accessed not only through telephone calls but also via text messages. a major development in recent years has been the mobile phone-based interventions for cessation which have been shown to be very promising. Text message interventions can increase the absolute quit rate by 4% (31). nicotine replacement therapies (nRTs) non-nicotine pharmacotherapies 40 41WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 INCrEaSED PrOPOrTION OF PEOPLE WHO aBSTaIN FrOm SmOKING FOr 6 mONTHS Or mOrE DuE TO a SPECIFIC INTErvENTION Print-based self-help Brief advice from physician Face-to-face behavioural Proactive telephone support Automated text messaging 0 2 4 6 8 10 12 18 20 14 16 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Single NRT Cytisine Buproprion Notriptyline Combined NRT Varenicline 0 2 4 6 8 10 12 14 16 18 20 A bs ol ut e in cr ea se in p ro po rt io n of p eo pl e w ho q ui t sm ok in g (p er ce nt ag e po in ts ) b Behavioural Interventionsa Pharmacological interventionsa Source: West et al (33) a Each bar represents the findings of a meta-analysis and the strength of evidence associated with each study will vary. b This represents the “projected percentage point increase in 6–12 month abstinence compared with no intervention”. The authors adjusted the published percentage point increase in 6–12 month abstinence to allow for direct comparison between each intervention where the meta-analyses did not use a comparator equivalent to “no intervention”. assessments were based upon the published effectiveness of the comparison intervention through a consensus Cessation interventions that work alongside other tobacco control measures, Brazil and USA When implemented together, tobacco control measures can work synergistically to increase the impact of each intervention. For example, when the united States raised the federal cigarette tax by uS$ 0.62 in early 2009, the number of calls to the quit line almost trebled – from 171 570 calls during January–may 2007 to 533 508 calls during the same period in 2009. and when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes – reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time (35). Pharmacological interventions Pharmacotherapy cessation interventions include nicotine replacement therapies (NrTs), as well as medications that do not contain nicotine but act to alleviate tobacco withdrawal symptoms. Both forms of therapy are effective aids to help people to quit tobacco use. Efficacy of pharmacotherapies is generally high, and compared to people who do not use an intervention, absolute quit rate increases can range from 6% for a single type of NrT to almost 15% for varenicline. Combining more than one NrT (patches and a faster-acting form) can also increase the effectiveness of NrTs (see Combined NrT in graph). Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining both behavioural and pharmacotherapy interventions, however, is more effective and can double the chances of successfully quitting (33). Mechanisms for developing tobacco cessation support Implementing tobacco cessation measures alongside other tobacco control policies maximizes their impact Tobacco cessation support has optimal effect when implemented in conjunction with other demand-reduction tobacco control policies, such as raising tobacco taxes, establishing smoke- free environments, banning tobacco advertising, promotion and sponsorship, printing large pictorial health warning labels on tobacco packages, and delivering anti-tobacco mass media campaigns. In turn, these tobacco control measures promote tobacco cessation by encouraging quitting and creating a supportive environment. a good example of synergising efforts is to include the local mCessation register portal/number, or quit line number, on cigarette and tobacco packs and on mass media anti-tobacco campaigns, which can significantly increase the demand for tobacco cessation services (36). using existing infrastructure to develop cessation support is feasible and affordable Integrating brief advice into existing primary health care systems is one of the first actions countries can take to develop tobacco cessation support. WHO FCTC article 14 Guidelines recommend that countries adopt a stepwise approach to develop and strengthen national tobacco cessation systems as rapidly and cost- effectively as possible (37). much of the needed infrastructure for promoting tobacco cessation measures, such as a primary health care system, already exists in most countries, making such promotion not only feasible but also affordable. Every country, therefore, can use their existing systems and resources to ensure that tobacco users at least receive brief advice. Every country can use its existing systems and resources to ensure that tobacco users at least receive brief advice, which can help motivate and support successful quit attempts. mCessation shows huge promise in India In 2015, a collaboration between WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, the Indian ministry of Health and Family Welfare, and the ministry of Communication and Information Technology led to the development of a short text message- based “mCessation” programme called QuitNow that supports and encourages tobacco users to quit. To evaluate the initiative, a total of 12 502 QuitNow subscribers were interviewed by telephone between 4–6 months after registration. Of those participants who had ever used tobacco, 19.1% self-reported that they had abstained in the preceding 30 days. Further research is needed to provide a more conclusive understanding of the impact of mCessation in India, but preliminary results show it has great potential to reach people who need support to quit tobacco (31). 42 43WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 STEPWISE aPPrOaCH TO DEvELOPING aND STrENGTHENING NaTIONaL TOBaCCO CESSaTION SySTEmS STEP 3 Medications Specialized treatment Increase the likelihood of quit attempts succeeding Prompt quit attempts STEP 1 Establish system components Address any issues related to health care workers Integrate brief advice into existing health systems STEP 2 Establish free, proactive quit line and/or mCessation service Incorporating brief advice into existing health care programmes has the potential to reach more than 80% of all tobacco users in a country each year if delivered routinely and widely across a health care system (38). Tobacco cessation interventions should be integrated into any existing health programmes in primary care where feasible, as well as disease and population-specific programmes such as national tuberculosis (TB) programmes (39), NCD programmes, oral health programmes (40), HIv/aIDS programmes, mental health programmes, and programmes addressing the needs of women’s, children’s and adolescents’ health. In particular, there has been a major drive globally to integrate cessation services into TB programmes and into sexual and reproductive health programmes. Both of these programmes reach populations at particular risk from the harms of tobacco and present an opportunity to address tobacco dependence when people make MINIMAL ExPANDED ADvANCED Brief advice integrated into primary care services Brief advice integrated into primary care and hospital services Brief advice integrated into primary care, hospital and specialized services Quit line: Toll-free quit line provided Quit line: Toll-free quit line provided mCessation: Text messaging mCessation: Text messaging Specialized tobacco dependence treatment services: behavioural counselling and/or medication EXamPLES OF mINImaL, EXPaNDED aND aDvaNCED CESSaTION INTErvENTIONSa a all countries should implement, at a minimum, brief advice. Once well established, countries can apply expanded and advanced measures, subject to resources. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Examples of cessation interventions linked to primary he lth care pro rammes Tobacco and tuberculosis Tobacco smoking increases the likelihood of acquiring, developing and dying from a TB infection. In 2013, the World Health assembly passed a resolution to approve the End TB Strategy. The strategy is based upon three pillars, one of which calls for integrated, patient-centred care and prevention. This provides an opportune platform to align the efforts against two global epidemics simultaneously, tobacco and TB. South-East asia’s regional response Plan for Integration of TB and Tobacco 2017–2021 (41) exists to help member States implement cost-effective cessation services through TB programmes and screen tobacco users for TB. all 11 countries in the South-East asia region have a national TB programme integrated into primary health care delivery systems to which a cessation service component could be added. Pilot studies integrating brief advice for tobacco cessation in TB patients that have been implemented in Bangladesh, India and Indonesia have demonstrated this intervention can be effective. India has since developed a Joint TB-Tobacco Framework, and is implementing the same through its National TB and Tobacco Control Programmes. Tobacco and reproductive health Tobacco use during pregnancy increases the risk of a large number of pregnancy complications including preterm delivery and spontaneous abortion, and other long-term health risks for both the mother and the unborn child. Successful treatment of tobacco use and dependence can have a significant effect on pregnancy-related outcomes and ongoing health outcomes in general. Integration of tobacco cessation services into reproductive health programmes is strongly recommended in the WHO recommendations for the Prevention and management of Tobacco use and Second-hand Smoke Exposure in Pregnancy (42). These guidelines state that health care providers should routinely offer advice to current tobacco users and recent tobacco quitters, as well as provide information to expectant mothers and, where possible, their partners or other household members about the harms of second-hand smoke. (potentially rare) contact with the health system. Countries should also consider leveraging existing infrastructure to provide wide- reach intensive behavioural support for tobacco users. many countries have existing call centres, substance abuse or other health-related hotlines that can be expanded to provide tobacco quit line services. Provide comprehensive tobacco cessation support and treatment when resources allow The cost and effectiveness of different cessation approaches vary, and therefore the affordability of the different approaches varies across low-, middle- and high-income countries. Overall, almost all population-level behavioural interventions are globally affordable, while intensive face-to-face therapy is affordable for middle- and high-income countries (33). If resources allow, countries should provide tobacco users with the highest level of support to facilitate a successful quit attempt. Countries may follow a stepwise approach to develop their tobacco cessation support systems. Combining behavioural and pharmacological interventions is the most effective way to quit, but uptake of interventions also relies on people’s preferences, which is likely to vary across different social and cultural contexts. Tobacco users may prefer using multiple tobacco cessation interventions, including health education materials, advice from health professionals, counselling (individual, group, or telephone), pharmacological therapy and other cessation services via text messaging or online tools (43, 44). Providing a diverse range of tobacco cessation support options, as often as possible, is also important to ensure maximal uptake and effectiveness. 44 45WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco cessation interventions: challenges and solutions About 30% of the world’s population have access to appropriate tobacco cessation services Ensuring cessation interventions reach the people who need them is a significant challenge. Currently, about 30% of the world’s population have access to appropriate tobacco cessation services (16). a recent study using Global adult Tobacco Survey (GaTS) data from low- and middle-income countries shows that fewer than 50% of smokers who interacted with a health care provider in the prior 12 months were screened for tobacco use or advised to quit (45). This represents a drastic missed opportunity to reach a large number of tobacco users. The impact of an intervention largely depends on both effectiveness and reach. So, finding practical ways to reach as many tobacco users as possible is key to achieving the impact that tobacco cessation support rates and act as a cost-effective marketing strategy to motivate large numbers of smokers to call a telephone quit line for quitting assistance (47, 48) The efficacy and cost- effectiveness of cessation programmes should be better recognized Tobacco control policies are, in general, highly cost-effective. Policies such as raising tobacco taxes can have a large impact with relatively few associated costs. In comparison, tobacco cessation programmes carry costs such as the staff time needed to provide brief advice; funding for NrTs and medications; and the employment of quit line counsellors. However, tobacco cessation programmes are highly cost-effective relative to other health systems activities and clinical interventions. The cost-effectiveness of quit lines and brief advice programmes combined is comparable to that of breast cancer screening (49). INTERvENTION AvERAGE COST-EFFECTIvENESS IN LOW- AND LOWER-MIDDLE-INCOME COUNTRIES AvERAGE COST-EFFECTIvENESS IN UPPER-MIDDLE- AND HIGH- INCOME COUNTRIES Provision of cost-covered, effective and population-wide support (including brief advice, national toll-free quit line services) for tobacco cessation to all those who want to quit, provided at 95% coverage Very high High Screening with mammography (once every 2 years for women aged 50–69 years) linked to timely diagnosis with pathology, staging, treatment with surgery +/- systemic therapy (endocrine therapy or chemotherapy) and management of treatment- related toxicities Very high High Source: WHO NCD Global action Plan (28). Tobacco cessation interventions should be responsive to vulnerable groups of people Cessation support systems are more effective if they account for and address the different social norms driving tobacco consumption as well as the difficulties associated with quitting tobacco use. The social context of tobacco users, such as gender, age, mental health status, and language and culture can deeply influence an individual’s experience with tobacco, including quitting. For example, evidence gathered from efficacy and effectiveness trials suggests that women may find it more difficult to achieve long-term abstinence than men. an understanding of the many factors that interact with gender and sex (including psychological, biological, pharmacological, social, environmental and cultural factors) and how they relate to cessation will likely help to design better cessation interventions that address these differences (50). There are also clear cases where lack of attention to particular social factors and contexts can decrease the chance of quitting. For example, in some countries females are less likely to be asked about their tobacco use status and less likely to be offered brief advice at primary care services, which may reflect health workers’ expectations of women and gender stereotypes (51). Ensuring that cessation initiatives are accessible and applicable to women, as well as youth, those with mental illness, minority ethnic groups speaking different languages, and other vulnerable groups can improve the reach and effectiveness of cessation policies. Few countries carry out regular monitoring and evaluation that helps them improve tobacco cessation services Evidence is key to providing the rationale for decision-makers to implement tobacco control policies and improve health services. although a great deal of evidence on the efficacy of tobacco cessation interventions is available, few countries carry out regular monitoring and evaluation that helps them understand the quality, effectiveness, reach, impact and cost of their tobacco cessation services. Lack of information showing the progress and outcome of tobacco cessation services at national level may prevent the identification of priority areas, quality improvement and further investment in tobacco cessation services. Commitment to tobacco cessation must be strengthened in many countries many countries still have no national tobacco cessation strategy. Only a few countries have dedicated personnel or clearly identified budgets for cessation programmes (52). Health care systems should assume primary responsibility for implementing tobacco cessation programmes,(37) but cessation support incorporated into primary care services that provides tobacco users with the resources to quit is still not widespread, and is especially rare in low-income countries. PrOPOrTION OF COuNTrIES INCOrPOraTING CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f c ou nt ri es c os t- co ve ri ng c es sa ti on su pp or t in p ri m ar y ca re fa ci lit ie s can potentially have on reducing the prevalence of tobacco use in a country. Many countries do not cover the costs of tobacco cessation services for those using them asking tobacco users to pay for tobacco cessation services (such as quit lines and medications) has proven to be a major barrier to service uptake, even in high-income countries. although most countries make NrT available without the need for medical assessment or prescription, the cost of purchase may limit access, especially for people on low incomes (46). Not all cost-coverage or insurance mechanisms cover NrTs and even when they do, some barriers exist where cost-coverage is available. For example, it may be that prescriptions by certain health professionals, like dentists (who can be trained in brief advice), are not eligible for reimbursement. It is critical for countries to cover the costs of tobacco cessation support for their tobacco users. research in New york City demonstrates that offering free NrT can increase quit CESSaTION INTErvENTIONS arE COST-EFFECTIvE 46 47WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 E-cigarettes and other products marketed as “cessation aids” In recent years the tobacco industry (and other non-tobacco commercial actors, such as those manufacturing e-cigarettes) has introduced a wide array of products, the majority of which simulate the act of smoking while typically delivering nicotine. There are currently three broad categories of these products: Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. Electronic non-nicotine delivery systems (ENNDS) are similar to ENDS but the heated solution delivered as an aerosol through the device does not generally contain nicotine. These products are aggressively marketed or promoted as cleaner alternatives to conventional cigarettes, as smoking cessation aids, or as “reduced risk” products. They have proliferated in several markets around the globe and present a unique challenge to regulators. While some of these products have lower emissions than conventional cigarettes, they are not risk free, and the long- term impact on health and mortality is as-yet unknown. There is insufficient independent evidence to support the use of these products as a population- level tobacco cessation intervention to help people quit conventional tobacco use. HTPs contain tobacco, and the use of these products constitutes tobacco use, thereby contributing to the burden of tobacco in countries where they are sold. In addition, the available evidence does not support the tobacco industry’s claim that these products are less harmful relative to conventional tobacco products (53, 54). There remains a great deal of uncertainty surrounding the potential toxicity of ENDS. although some have been shown to help smokers quit conventional smoking under certain conditions, when used as NrTs (55, 56) the scientific evidence is inconclusive (57–59). There have only been a limited number of randomized control trials and longitudinal studies investigating the role of ENDS as potential cessation aids offered to a population, and their conclusions are equivocal (57, 59). Two reviews, in 2016 and 2017, established that no credible conclusions could be drawn from the available studies (57, 59). This is consistent with the conclusion of the National academy of Sciences in its 2018 review of evidence on ENDS (referred to as e-cigarettes in this and the subsequent reports), in which it stated that “overall, there is limited evidence that e-cigarettes may Given the scarcity and low quality of scientific evidence, it cannot be determined whether ENDS may help most smokers to quit or prevent them from doing so (FCTC/COP7/11). be effective aids to promote smoking cessation” (60). By contrast, a randomized control trial of e-cigarettes versus nicotine replacement therapy concluded that “e-cigarettes were more effective for smoking cessation than nicotine replacement therapy when both products were accompanied by behavioural support” (61). However, the study has several limitations and any consideration of the results must be done with caution. For example, although those who were assigned e-cigarettes were more likely to abstain from using traditional cigarettes as compared to those who were assigned NrT, 80% of the e-cigarette user group continued to use e-cigarettes one year after the study started. This is compared to a very small percentage of people in the NrT arm of the study who continued to use NrTs. In most countries where they are available, the majority of e-cigarette users continue to use e-cigarettes and cigarettes concurrently, which has little to no beneficial impact on health risk and effects (62). at the same time, some reviews have also suggested that e-cigarettes could in fact hinder smoking cessation (63). Further, beyond the scope of cessation, novel and emerging tobacco and nicotine products are increasingly being taken up by never users of tobacco (64). These products therefore play an important role in expanding the market of nicotine users, with a high associated risk for addiction, particularly among children and adolescents. Misinformation by the tobacco industry about e-cigarettes is a present and real threat The scientific evidence on e-cigarettes as cessation aids is inconclusive and there is a lack of clarity as to whether these products have any role to play in smoking cessation. There are also real concerns about the risk they pose to non-smokers who start to use them, especially young people. unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids. as ENDS are increasingly introduced to the market, careful monitoring of cessation rates is vital. The possibility of tobacco industry interference in tobacco cessation efforts through misinformation about the potential benefits of these products – which are presented as alternatives but in most cases are complementary to the use of conventional tobacco products – is a present and real threat. This issue and other concerns surrounding ENDS and HTPs are discussed in further detail in the following sections of this report. Maximizing cessation efforts Governments should make greater political and financial commitments to promote tobacco cessation Implementing tobacco cessation measures can help significantly reduce the prevalence of tobacco use and save lives (65, 66). It is estimated that if tobacco 48 49WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved (19). If the tobacco-related global NCD and SDG targets are to be achieved, governments need to rank tobacco cessation as an important public health priority and invest in it accordingly. article 14 of the WHO FCTC identifies a blueprint for more assertive support for cessation. Key recommendations include the following activities. Promote tobacco cessation support as part of a comprehensive tobacco control programme Cessation programmes are more effective when they are part of a comprehensive tobacco control programme. Countries should accelerate full implementation of the WHO FCTC, including the provisions in article 14, which relates to tobacco cessation and treatment. Recognize tobacco cessation support as an essential component of universal health coverage Helping tobacco users to quit is one of the most cost-effective preventive services in primary care. WHO recommends tobacco cessation as one of the essential noncommunicable disease interventions for primary care in low-resource settings (WHO PEN: https://www.who. int/ncds/management/pen_tools/en/) because of its importance in prevention and management of NCDs such as cardiovascular diseases, cancer, chronic respiratory diseases and diabetes. Countries should include tobacco cessation support in their universal health coverage intervention package in order to provide people-centred health services in primary care. at a minimum, countries should ensure that health care workers are trained to offer brief advice as part of all existing health care programmes in primary care and make the documentation of tobacco use mandatory in patients’ medical records. Training in tobacco cessation should be part of all health care professional training curricula and part of a mandatory training programme across health care professions. Training health care workers to routinely deliver brief advice can be achieved through a one-day workshop or even using an online training course. To assist countries in their efforts to integrate brief advice into primary care, WHO has developed a comprehensive training package, Strengthening health systems for treating tobacco dependence in primary care (67), and an e-Learning course, Training for primary care providers: brief tobacco interventions (available at https://www.who.int/tobacco/quitting/ training-for-primary-care-providers/en/), which are accessible to anyone free of charge. Earmarking tobacco taxes for cessation: an innovative programme in Thailand Funded by revenue from tobacco and alcohol excise taxes, the Thai Health Promotion Foundation (ThaiHealth) has supported several smoking cessation projects. For example, it has continuously funded the National Tobacco Quit Line since 2009, treating up to 22,000 smokers a year with a success rate of 33% (70). Since 2016 it has funded the ministry of Public Health to improve tobacco cessation services in all its hospitals. ThaiHealth – together with the ministry of Public Health and all other stakeholders – has also created and launched a project called “Three million smoking quitters in three years”. This project, which started in June 2016 and which finished at the end of may 2019, encouraged the ministry of Public Health’s 1 million village volunteers in the health service system to help one smoker per year successfully quit smoking for at least 6 months (through asking people to give up completely at the community level and/or referring them for support from the ministry’s tobacco cessation services if needed). If successful, this project will get 1 million people to quit each year, totaling 3 million quitters in 3 years. In November 2018 the minister of Public Health announced that the project will be one of the indicators used to evaluate the performance of all high-level ministry administrators – an announcement that spurred the project to redouble its efforts. The ministry announced in January 2019 that about 1.7 million smokers had started to quit tobacco with the programme. Establish a sustainable source of funding for tobacco cessation support The strengthening or creation of national infrastructure to promote and provide tobacco cessation support and services requires both financial and technical resources, so it is essential to identify a sustainable funding source. Countries should consider placing the cost of tobacco cessation support on the tobacco industry and other retailers through measures such as designated tobacco taxes; tobacco manufacturing and/or import licence fees; a tobacco-selling licence for distributors and retailers; and noncompliance fees levied on the tobacco industry and retailers. Offering a level of reimbursement or financial incentive can have a significant impact on both the uptake of cessation treatment as well as the likelihood of patients adhering to the treatment (68). Interventions that reduce the cost of cessation treatment to smokers not only increase the number of people who attempt to quit, but also increase the likelihood of their success in quitting (69). Promote public-private partnerships and engage different stakeholders It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. The public-private partnerships (which exclude the tobacco industry and its funded foundations) could extend the depth and breadth of funding and tobacco cessation services to be offered in countries. For example, many national or provincial quit lines are resourced by a combination of governmental and nongovernmental funding. Private insurers and employers can also offer incentives (such as reduced insurance premiums or access to employee benefits) to help motivate successful use of cessation services, given the reduction in health care costs and improvements in productivity that can be expected following cessation of tobacco use. Prioritize population-level tobacco cessation approaches resources are finite. In order for tobacco cessation interventions to reach as many tobacco users as possible at the lowest achievable cost and have the most impact, governments should prioritize population- wide tobacco cessation approaches and consider adopting the three population- wide approaches as recommended by WHO Global Noncommunicable Disease action Plan 2013–2020: integrating brief advice into primary care, providing national toll-free quit line services, and making mCessation support available. Embrace innovative approaches to improve the reach of tobacco cessation interventions an important aspect of SDG 9 on industry, innovation and infrastructure is the recognized need for people to have adequate access to information and 50 51WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 and wearable technology for example, can help to bring about major impacts on reducing prevalence of tobacco use globally. Build effective communication strategies Public awareness campaigns should be designed to make clear the efficiency and cost-effectiveness of tobacco cessation interventions among the general public and the tobacco control community. It is also essential to build effective communication that informs people about the different forms of support available, and where to access it. Consistent messages from health care professionals carries weight. Campaigns should be carefully designed to target specific audiences in different contexts so they maximize understanding and gain the popular support needed for success. Monitor and evaluate all tobacco cessation strategies and programmes monitoring and evaluation are essential to ensure that the best means are employed to formulate evidence-based and cost- effective tobacco cessation interventions that help users quit tobacco. The ability to learn from the experiences of developing and implementing tobacco cessation programmes has been hampered by the limited availability and quality of data, especially in low- and middle-income countries. Countries should continue to monitor and evaluate current tobacco cessation strategies and programmes, including process and outcome measures, to observe trends and impacts over time. Building close collaborations with academic institutions, national statistics offices, nongovernmental organizations and other stakeholders will help to develop appropriate monitoring and evaluation methods, and to design stronger and more tailored services. Maintain caution where novel and emerging tobacco and nicotine products are concerned Policy action and health interventions should be based upon robust scientific evidence. Where evidence is not sufficiently available on the potential harms of new products, countries must maintain caution by ensuring that legislation is up-to-date and sufficiently protective of population health. services. Emerging technologies must be harnessed to ensure that populations have access to information about the dangers of tobacco use through popular forums such as social media; in addition, the further development of interventions using mobile phones and other digital platforms should continue. research and development into innovative ways to utilize such advances as mobile technologies and artificial intelligence in cessation interventions should also be encouraged. We currently know what interventions work but they do not yet reach a sufficient number of tobacco users. Increasing the reach and access to cessation services, through mHealth It is essential that governments and nongovernmental organizations work in partnership to accelerate the implementation of cessation measures and curb the harms of tobacco use. 52 53WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Heated tobacco products Heated tobacco products contain tobacco Heated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco or activation of a device containing the tobacco. These aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavoured. The tobacco may be in the form of specially designed cigarettes (e.g. “heat sticks”, “Neo sticks”) or pods or plugs. HTPs differ not only to conventional cigarettes, but also to electronic nicotine delivery systems (ENDS, some of which are called e-cigarettes), as ENDS do not contain tobacco, but rather a nicotine solution. These boundaries, however, are increasingly difficult to define. Today there is a growing presence of emerging “hybrid” tobacco products that contain both nicotine solution and tobacco. Examples of HTPs include IQOS from Philip morris International (PmI), Ploom TECH from Japan Tobacco International (JTI), Glo from British american Tobacco (BaT) and PaX from PaX Labs. The evidence on HTPs is inconclusive While HTP technology has been around since the 1980s, new generations of products that have become popular in the past 5 years have different features and operating mechanisms to earlier versions. This means that although research has been conducted on HTPs since their emergence, conclusions on earlier products cannot be applied to later ones. Given that the newer generations of products have not been on the market for long enough, evidence on their health impacts is sparse. Further, much of the existing science on HTPs is industry- generated, and thus potentially weakened by bias arising from a conflict of interest. HTPs should be regulated as a tobacco product Currently, HTPs are available in more than 40 countries. While they are banned in few countries, there is significant variation in how they are regulated in others. many factors affect a country’s ability to control and regulate the use of HTPs, including national regulatory powers, enforcement capacity regulatory frameworks, country capacity and tobacco industry interference. As with other tobacco products, MPOWER measures apply to HTPs HTPs are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. mPOWEr measures help WHO member States to implement the demand reduction articles of the WHO FCTC and are equally applicable to HTPs as they are to other tobacco products. This is well articulated qUESTION SUMMARy OF THE EvIDENCE Do HTPs contain harmful chemicals? From available evidence we know that many of the harmful chemicals that are generated by HTPs are similar to those generated by conventional cigarettes, but generally at lower levels (71, 72). However, there is also some evidence that there are new chemicals in HTPs that are not present in the emissions of conventional cigarettes, and which could have some degree of toxicity and associated harm (53). Are HTPs less harmful than cigarettes? To date, the available evidence demonstrates that exposure to harmful and potentially harmful chemicals from these products may be lower relative to cigarettes (73) (but higher compared to electronic nicotine delivery systems (ENDS), see next section). However, the evidence does not show that these products will reduce tobacco-related diseases, or that they are exclusively used as substitutes for cigarettes. If they attract users who were not previously tobacco users, their overall impact on health would be negative. Are HTPs useful as a cessation aid? HTPs are tobacco products and therefore, even if a tobacco user converts from the use of conventional cigarettes to HTPs, this would not constitute cessation. Claims that smokers switch from conventional cigarettes to exclusive use of HTPs are unsubstantiated (74). Further independent studies are needed to gather more information and inform policy options. in WHO’s information sheet on heated tobacco products, which provides guidance on how these products should be regulated (75), as well as Decision FCTC/COP8(22) for novel and emerging tobacco products. HTP marketing must be closely monitored and regulated The marketing of HTPs is one of the biggest challenges to tobacco control efforts. Products are widely promoted using messages that explicitly or implicitly claim they are safer and less toxic alternatives to conventional cigarettes (53). manufacturers exploit the lack of clear consensus on the specific forms of harm caused by HTPs to confuse consumers and evade existing regulation and avoid the introduction of regulations that cover these products. For example, while HTPs are widely marketed as safer alternatives for smokers, manufacturers are generally careful to qualify their claims or include a waiver (76). One claim often made by manufacturers is that the aerosol produced from HTPs contains lower quantities of harmful constituents than cigarette smoke and are therefore less harmful to health (76). However, phrases such as “likely to cause less harm” or “with potential to cause less harm” do not mean this demonstrates reduced risk. 54 55WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 n HTPs contain tobacco and should be regulated like tobacco products. n HTPs produce toxic emissions, many of which are similar to toxicants found in cigarette smoke. n HTP users are exposed to toxic emissions from the products, and bystanders could also be exposed to these toxic second- hand emissions. n Although the levels of several toxicants in HTPs are lower than those found in conventional cigarettes, the levels of others are higher. A lower level of some toxicants does not necessarily mean a reduction in health risk. n HTPs contain nicotine. Nicotine is highly addictive and linked to health harms, particularly in children, pregnant women and adolescents. n The long-term health impacts of HTP use and exposure to their emissions remain unknown. There is currently insufficient independent evidence on the relative and absolute risk. Independent studies are needed to determine the health risk they pose to users and bystanders. Key information and recommendations for countries Heated tobacco products (HTPs) are tobacco products. This means that Parties’ obligations under the WHO FCTC apply to HTPs in the same way as they apply to conventional cigarettes. most marketing of HTPs deliberately tries to position them as different to cigarettes. They are promoted as “smoke-free” through claims that the aerosols they produce are not smoke and that HTPs do not produce tar. This means they are often marketed as a more environmentally friendly and socially acceptable alternative to cigarettes. In addition, HTPs are extensively promoted as modern, high- tech and high-end lifestyle products, with minimalist designs, a presence in flagship stores, and high-profile product launches that portray them as attractive and harmless luxury consumer products. all of these efforts make use of social positioning techniques that were previously used to market cigarettes, and which are particularly effective in targeting young people. ultimately, in line with WHO guidance, all forms of tobacco use are harmful, and this includes HTPs. Tobacco is inherently toxic and contains carcinogens, regardless of whether it is consumed as a smoked or smokeless product (75). Overall, given the information we have and the fact that these products contain tobacco, they must be regulated as tobacco products. They should be subject to the same policy and regulatory measures applied to all tobacco products, in line with the WHO FCTC. 56 57WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Electronic nicotine delivery systems Electronic nicotine delivery systems are diverse and increasingly available Electronic nicotine delivery systems (ENDS) are devices that heat a liquid to create an aerosol that is inhaled by the user. The liquid contains nicotine (but not tobacco) and other chemicals that may be toxic to people’s health. “ENDS” is an all-encompassing term for multiple product categories. The most common ENDS are “electronic cigarettes”, also known as “e-cigarettes”, “vapes”, or “vape pens”. Other categories of ENDS include “e-hookahs”, “e-pipes” and “e-cigars”. Some of the products resemble their conventional tobacco counterparts: cigarettes, cigars, cigarillos, pipes or hookahs; others are shaped more generically like pens, uSB memory sticks, or basic cylinders. There are also different forms of nicotine used in these products. recently, nicotine salts have been used to deliver high levels of nicotine. The diversity of product groups has evolved over time and according to different geographic and/or demographic markets. There are other electronic, non-nicotine delivery systems (ENNDS,) which are essentially the same as ENDS but the liquid used generally does not contain nicotine (although upon testing many “zero-nicotine” solutions are found to contain nicotine). This report only addresses ENDS and does not cover ENNDS. Examples of ENDS include Juul from Juul Labs, vype from British american Tobacco, blu from Imperial Brands. Evidence on the health risks associated with EnDS remains inconclusive WHO has extensively reviewed and summarized the available evidence on ENDS and finds that the evidence to date is inconclusive. It is important to note that ENDS are a diverse group of products, containing a wide variety of nicotine dosages, flavours, and emissions. as a result, the unique characteristics of a particular type of ENDS – such as chemical content, heat source or how and where it is used – will play a major role in its effects on people’s health. a more robust determination of the effects of ENDS will require vigorous investigation into the health outcomes of large cohorts of well-characterized users over a longer period of time. qUESTION SUMMARy OF EvIDENCE What are the consequences of taking up ENDS use at a younger age? Recent surveys in the United States of America (USA) and some European countries have shown marked increases in ENDS use amongst youth (77). Between 2011 and 2018 in the USA, youth e-cigarette use rates have risen from 1.5% to a staggering 20.8% (78). Young people who use ENDS are exposed to nicotine, which can have long-term effects on the developing brain and there is a risk of nicotine addiction, given that tobacco product use is primarily established in adolescence (79). Furthermore, there is a growing body of evidence in some settings that never-smoker minors who use ENDS at least double their chance of starting to smoke cigarettes later in life (80, 81). What is the harm of ENDS relative to conventional cigarettes? ENDS’ aerosols are likely to be less toxic than cigarettes but there is insufficient evidence to quantify the precise level of risk associated with them (82). Also, many factors will impact on the relative risk associated with their use. For example, the amount of nicotine and other toxicants in the heated liquid. What are the health effects associated with ENDS? ENDS pose risks to users and non-users (82). There is insufficient evidence to quantify this risk and the long-term effects of exposure to ENDS’ toxic emissions are unknown (77, 82). In addition to risks associated with emissions of ENDS there are also risks of physical injury brought about by fires or explosions related to ENDS devices (83). Do ENDS help smokers quit tobacco? As discussed in the background chapter on “O” – Offer help to quit, the scientific evidence regarding the effectiveness of ENDS as a smoking cessation aid is still being debated. To date, in part due to the diversity of ENDS products and the low certainty surrounding many studies, the potential for ENDS to play a role as a population-level tobacco cessation intervention is unclear (57–59). The potential impact of ENDS on public health has been heavily debated since their introduction to consumer markets 12–15 years ago. EnDS are not harmless and must be regulated according to WHO, member States that have not banned ENDS should consider regulating them as harmful products, and governments should implement the regulatory measures for ENDS that they determine are most appropriate for their domestic context. This may entail, for example, regulating ENDS as tobacco products, products imitating tobacco, or as a specifically defined category. although the specific level of risk associated with ENDS has not yet been conclusively estimated, ENDS are undoubtedly harmful and should therefore be subject to regulation. MPOWER measures can be applied to EnDS Like any product that can cause harm and damage health, all ENDS products should be regulated and existing and effective policy toolkits, like mPOWEr, can be applied productively to ENDS. Guidance provided by the WHO report to the 2014 Conference of the Parties (FCTC/COP/6/10 rev.1) is outlined in the following box (82). (a) impede ENDS promotion to and uptake by non-smokers, pregnant women and youth; (b) minimize potential health risks to ENDS users and non-users; (c) prohibit unproven health claims from being made about ENDS; and (d) protect existing tobacco-control efforts from commercial and other vested interests of the tobacco industry. ENDS regulation should: 58 59WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 M Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess developments in ENDS use, disaggregated by important factors such as sex and age. P ENDS users should be legally banned from using ENDS indoors, especially where smoking is banned, until exhaled vapour is proven to be not harmful to bystanders and reasonable evidence exists that smoke-free policy enforcement is not undermined. This is because there is a reasonable expectation on the part of bystanders that there is not a “diminished risk” in comparison to exposure to second-hand smoke, but rather “no risk increase” from any product in the air they breathe. O The evidence on the use of ENDS as a potential cessation aid is still being debated. Some evidence has suggested ENDS may work as a cessation aid for some people. However, the evidence required to support the role of ENDS as an intervention at population scale is limited. ENDS should therefore not be promoted as a cessation aid until adequate evidence is compiled on specific types of ENDS products and the public health community can agree upon the effectiveness of those specific products. W ENDS health warnings should be commensurate with proven health risks. In this regard, the following risk warnings could be considered: potential nicotine addiction; potential respiratory, eyes, nose and throat irritant effect; potential cardiovascular risk; potential adverse effect on pregnancy (due to nicotine exposure). E Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, contemplate putting in place an effective restriction on ENDS advertising, promotion and sponsorship. Any forms of ENDS advertising, promotion and sponsorship must be regulated by an appropriate governmental body. If this is not possible, an outright ban on ENDS advertising, promotion and sponsorship is preferable. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1(82). R While they are generally less toxic than tobacco cigarettes, ENDS still carry health risks. The existing evidence shows that ENDS aerosol is not merely “water vapour” as is often claimed in the marketing for these products. ENDS use poses serious threats to adolescents and fetuses. In addition, it increases exposure of non-smokers and bystanders to nicotine and a number of toxicants. Taxes should therefore be applied to these products in line with national standards to prevent uptake, particularly by young people. EnDS have the potential to undermine tobacco control efforts There are a number of challenges associated with regulating ENDS, which are often cited as “reduced harm”, “reduced risk”, or “clean alternatives” compared to conventional tobacco products. Because of these claims there are a number of consequences to public health and tobacco control. For instance, public health officials are concerned by the possibility that these devices serve as a “gateway” to conventional smoking among young people. ENDS are heavily marketed towards youth through the use of flavouring and promotional strategies. apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. Further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ENDS are employing tactics to expand their consumer base under the guise of contributing to public health work. ENDS products also have the potential to undermine existing tobacco control measures by, for instance, exempting these products from taxation or by allowing their use in smoke-free places. There is already significant confusion about (and conflation of) product categories. It can be very difficult to differentiate, for example, an ENDS product from an HTP. This can be used to the advantage of the industry as is further discussed in the next chapter. Further, as ENDS and other novel products continue to evolve there is also the risk that they will fall through regulatory gaps and loopholes. Since WHO’s initial evaluation of the evidence on the health risks of ENDS, their effectiveness in helping people quit smoking, and their impact on tobacco control, many additional articles have been published. However, given the diverse nature of ENDS and the many advances in product development since research began, more evidence is still needed to inform a conclusive statement on their health impacts and potential as a cessation tool. until then, there are a number of unknown factors which mean they cannot be safely recommended for consumption. n ENDS should be carefully and clearly defined in the legislation in order that countries can regulate ENDS effectively. n Countries often have the option of classifying ENDS as tobacco products. If this is possible then countries should ensure that existing tobacco control laws adequately protect people from the potential harms of ENDS. n ENDS products may serve as a gateway to conventional smoking among young people or the renormalization of smoking in society. n Countries should apply bans on advertising and flavouring of products to deter use by young people. n Countries should consider introducing policies to force manufacturers to make products unattractive to young people in order to discourage uptake, such as plain packaging. Key information and recommendations for countries Nicotine is addictive and ENDS use could lead people, particularly young people, to take up more harmful forms of tobacco consumption. 60 61WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Tobacco industry interference: the greatest obstacle to reducing tobacco use The tobacco industry has a long history of systematic, aggressive, sustained and well-resourced opposition to tobacco control measures (84), including efforts to subvert life-saving tobacco control measures. It does this by deploying a wide variety of tactics to obstruct, delay, weaken or undermine political commitments and tobacco control measures taken by countries at international, regional, national and subnational levels. While some strategies are public and others more covert (be they directed at governments, the public, or the media), all have the goal of weakening tobacco control. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. In 2011, the united Nations General assembly recognized “the fundamental conflict of interest between the tobacco industry and public health”(85). recognizing this clear, irreconcilable conflict of interest, and despite ongoing attempts by the industry to position itself as a legitimate partner and stakeholder in tobacco control, Parties to the Convention must comply with their obligations under article 5.3 of the WHO FCTC, which requires that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law”(1). n intimidating governments with litigation or the threat of litigation; n manipulating public opinion to gain the appearance of respectability. new industry players continue to subvert tobacco control Just over a decade ago, ENDS and ENNDS entered the market, with the most common prototype being e-cigarettes. at first these products were predominantly developed and marketed by non- tobacco companies such as Pax Labs, which introduced JuuL (a popular ENDS product among young people in the uSa) Philip Morris International-funded Foundation for a Smoke-Free World The Foundation for a Smoke Free World is funded solely by tobacco giant Philip morris International (PmI) with a commitment of uS$ 80 million annually over 12 years (approximately uS$ 1 billion) (86). It is part of an ongoing industry strategy to influence the scientific and policy agendas. The Foundation funds research programmes and studies that are supportive of products marketed by PmI and other producers as “reduced risk”, and offers funding to governments, universities, uN agencies, other international bodies and the public health community to encourage smokers to use such products, presumably in place of traditional cigarettes. In September 2017 WHO issued an official statement indicating that it will not partner with the Foundation, and recommending that governments and the public health community follow this lead (87). The WHO FCTC Secretariat has been similarly forthright in its rejection of the Foundation, stating in its WHO Framework Convention on Tobacco Control Secretariat’s statement on the launch of the Foundation for a Smoke-Free World that it is a clear attempt to breach the WHO FCTC by interfering in public policy “aimed at damaging the treaty’s implementation, particularly through the foundation’s contentious research programmes” (88). In 2019, the Foundation subsequently wrote to members of the WHO Executive Board, urging WHO to amend its stance on the Foundation, and to “review and consider how best to work with the Foundation to facilitate a rapid reduction in the use of lethal cigarettes”. This proposal was rejected by the Director-General, who reiterated WHO’s position in its 2017 statement (89). Tobacco industry interference takes many forms Common general tactics employed by the tobacco industry in opposing tobacco control include (16): n interfering with political and legislative processes; n fabricating support through front groups; n influencing the scientific and policy agendas; n making unproven claims and discrediting proven science; n exaggerating the economic importance of the industry; in 2015. Due to the success of these products, the tobacco industry has heavily invested in such markets and diversified into manufacturing them alongside new-generation tobacco products such as heated tobacco products (HTPs). In December 2018, tobacco company altria acquired a 35% stake in JuuL for uS$ 13 billion. Other tobacco companies such as British american Tobacco and Japan Tobacco International also have significant investment in such products (90). 62 63WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Philip Morris’ “Unsmoke” campaign: a case of smoke and mirrors Stopping Tobacco Organizations and Products (STOP) Philip morris International (PmI) is one of the world’s largest cigarette manufacturers and a persistent opponent of tobacco control. Despite this, PmI is attempting to position itself as a responsible public health partner, and to influence the tobacco control agenda. Part of this is PmI’s “unsmoke” campaign, which encourages people “who don’t quit cigarettes” to “change to a better alternative”, in line with PmI’s goal to “replace cigarettes with the smoke-free products we’re developing and selling”. The campaign undermines tobacco cessation initiatives by presenting an easy alternative to breaking a nicotine addiction, and by undermining successful tobacco control initiatives (which have denormalized smoking in many countries) by portraying this form of tobacco use as socially acceptable. PmI refers to both its HTPs and ENDS as “smoke-free products”. This strategy creates confusion between the product categories and promotes the industry claim that emissions from HTPs and ENDS are not “smoke” (though emissions from HTPs contain many of the toxic chemicals found in cigarette smoke). The campaign also fails to acknowledge that the impact of short- and long-term use is largely unknown, and that current science does not support claims of reduced risk of health harms from HTPs. PmI avoids saying the products are less harmful, but instead states that it “believes” these products “while not risk free … have the potential to present less risk of harm than continued smoking”.1 Through promotion and lobbying by PmI and its front groups such as the Foundation for a Smoke Free World, this campaign seeks to pressure governments to allow these products into domestic markets and exempt them from tobacco control regulation, in particular TaPS bans, taxes and smoke free laws, thereby undermining tobacco control initiatives and weakening WHO FCTC implementation. The tobacco industry is the single greatest barrier to reducing deaths caused by tobacco use. To perpetuate sales of its products, the industry needs the weakest possible regulatory environment. In other words, it needs to make sure tobacco control policies do not come into effect or are rendered ineffective. The industry uses many strategies to accomplish this goal. In 2018, Bloomberg Philanthropies established STOP (Stopping Tobacco Organizations and Products) – the first global tobacco industry watchdog. STOP’s mission is to expose the industry’s behaviour that undermines public health and to support efforts to counter industry interference in policy. STOP works around the world, with a special focus on low- and middle- income countries where the industry is aggressively targeting communities and where the biggest populations are at risk of tobacco-related disease. STOP provides a platform for advocates, policy-makers and journalists to access the latest information on the tobacco industry – including exposés on abuses and tactics, analyses on industry behaviour and new tools to fight industry interference. STOP’s work consists of: n collecting data and investing in comprehensive research; n responding to policy-makers’ requests for help through a rapid response service; n exposing and challenging the industry’s strategies by engaging with local and international media; n collaborating across the tobacco control network and other sectors to ensure a comprehensive approach to countering industry tactics. In its first 6 months, STOP galvanized support for WHO from more than 279 organizations and individuals in 50 countries to publicly reject an approach for collaboration from a Philip morris International-funded foundation. STOP also exposed dozens of organizations from more than 20 countries as industry allies that have worked to support tobacco-friendly policies. Policy-makers, advocates and journalists can search a public database for those groups in their countries and read the evidence that links them to the industry. STOP is comprised of a partnership between The Tobacco Control research Group at the university of Bath, The Global Center for Good Governance in Tobacco Control, The union’s Department of Tobacco Control, and vital Strategies. To learn more, visit: exposetobacco.org. Countering tobacco industry tactics Commitment to countering industry interference is fundamental to successful implementation of effective tobacco control measures in accordance with the WHO FCTC – article 5.3 of which obliges Parties to act to protect public health policies from commercial and other vested interests of the tobacco industry in accordance with national law. In 2008, the Conference of Parties (COP) to the WHO FCTC adopted guidelines for the implementation of article 5.3. The Guidelines were developed based on both scientific evidence and the experiences of Parties (91). The purpose of the Guidelines is “to ensure that efforts to protect tobacco control from commercial and other vested interests of the tobacco industry are comprehensive and effective”. They state clearly that governments should limit interactions with the tobacco industry and avoid partnerships with it, and that governments should not accept financial or other contributions from the tobacco industry, or those working to further its interests. The Guidelines continue to be instrumental in combatting tobacco industry interference and should be applied to both conventional and emerging tobacco markets where, as already described, the tobacco industry attempts to present itself as a partner in tobacco control and harm reduction, while simultaneously blocking regulatory efforts. Effective government action to counter tobacco industry interference in cessation includes the following: n requiring disclosure of, and clearly communicating, funding sources for research institutions, academics, and scientific studies to prevent unseen biases in science on which policy may be based, as well as to clarify the motivations of nongovernmental organizations, business and trade associations, consumer groups, think tanks, professional associations and others seeking involvement or input in tobacco control policies. n rejecting partnerships and non- binding or non-enforceable agreements with the tobacco industry and those working in its interests, including financial support and endorsement of tobacco industry activities related to tobacco control. n raising awareness about the known addictive and harmful properties of tobacco and nicotine-containing products, and about tobacco industry interference with tobacco control policies. n Denormalizing and, to the extent possible, regulating and banning publicity around activities described as “socially responsible” by the tobacco industry. n requiring that the tobacco industry is held accountable for misinformation presented in marketing campaigns. n regulating HTPs as tobacco products in accordance with the WHO FCTC and regulating ENDS in accordance with the relevant COP decisions (Decision FCTC/COP6 and Decision FCTC/COP7). n requiring that information provided by the tobacco industry be transparent and accurate, with regular, truthful, complete and precise information on tobacco industry activities. n Effective conflict of interest policies in place and enforced for policy-makers and officials engaged in developing, implementing and enforcing tobacco control policy. Blocking tobacco industry interference is critical to successfully addressing the global tobacco epidemic and decreasing the public health consequences of tobacco use. 1 See: https://www.pmi.com/glossary-section/glossary/smoke-free-products (accessed 04/06/2019) 64 65WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Industry tactics that interfere with tobacco cessation The tobacco industry has in recent years become increasingly vocal in the promotion of products it claims can help people quit conventional smoking. These products, which include HTPs, ENDS and ENNDS are often promoted by the industry as “reduced risk” (relative to cigarettes) and/or cessation products that can help tobacco users or smokers of conventional products to quit conventional smoking. Such activities have ramifications for genuine initiatives to assist tobacco cessation, as they have the potential to misinform and mislead consumers and confuse governments. In this respect, the Guidelines for Implementation of article 14 of the WHO FCTC define the phrase “tobacco cessation” as “the process of stopping the use of any tobacco product, with or without assistance”. Making unproven claims and influencing research at the time of writing, the evidence is insufficient to recommend the use of ENDS as cessation devices at the population level. Existing studies have significant limitations, including selection bias, inadequate measures of exposure, and poor controls. moreover, a substantial amount of the available literature is funded by product manufacturers including in the tobacco industry, whose commercial interests pose an unavoidable conflict of interest (60). In the case of HTPs, because they are tobacco products, switching from conventional tobacco products such as cigarettes to HTPs is not considered tobacco cessation. In this context, there is a risk that industry marketing strategies focused around “quitting” or “switching” will lead consumers, regulators and decision-makers to conflate the two concepts. Conflation of product categories The tobacco industry has exploited the division in the public health community (resulting from the inconclusive evidence on the merits of these products as cessation aids) on the potential benefit of ENDS as a cessation aid. Consequently, some countries have lenient regulations for ENDS relative to conventional tobacco products, and where this is the case, the tobacco industry often leverages this by pitching HTPs as electronic products similar to ENDS to negotiate regulatory treatments similar to ENDS. This creates confusion between these product categories, which can result in the limited evidence that may support some forms of ENDS as a cessation aid under certain conditions being falsely attributed to HTPs too. For example, the name of the Philip morris International HTP product “iQOS” (which is an acronym for “I quit ordinary smoking” (72)) can contribute to this erroneous impression. Some countries and regions, including the uK, France and the Eu have left the option open to have new and novel products licensed as pharmaceutical products by including provisions in their relevant laws or directives, pending the evidence to support this and approval by relevant bodies. However, according to the information we currently have, none of these products is available commercially as a cessation aid. HTPs are often promoted, especially to regulators, as “conventional smoking cessation” aids. However, there is limited evidence on the impact of HTP use on conventional smoking or on the relative harm of HTP use as compared to conventional cigarette smoking. Manipulating public opinion to gain the appearance of respectability The recent positioning of big tobacco companies as proponents of “harm reduction” is a good example of a manipulative tobacco industry strategy. Extensive, high-profile messaging, misinformation based on unsubstantiated claims and lobbying by companies presenting themselves as part of the solution to reduce tobacco use prevalence may influence public opinion. Such lobbying promotes a new portfolio of products claimed to be “reduced risk”, “odour free” or “smoke-free”, and to offer “cleaner alternatives” to conventional cigarettes. This portrays the tobacco industry as responsible partners in the fight to end adult smoking, while downplaying established facts that cigarettes still comprise 97% of the worth of the global tobacco market which is dominated by the same companies. Strategic advertising to sustain nicotine or tobacco use ENDS/ENNDS and HTPs are openly advertised as a way to circumvent smoking bans. Industry promotions aim to distance these products from cigarettes, claiming that they “do not involve combustion” and produce “vapour” rather than smoke, which is used as a basis for arguing that the products should be exempt from smoke-free and other laws. representatives of flagship stores are highly trained and skilled in luring potential consumers into their stores, and quick to offer these products as more pleasurable than smoking or using traditional tobacco products, sometimes arguing that they are more socially acceptable and can be used in smoke-free places. Such interference could deter quit attempts by would-be quitters as these products are aggressively marketed to sustain nicotine or tobacco use. This may also have implications for tried and tested nicotine and non-nicotine pharmacotherapies (which are proven to help smokers to quit tobacco use), as instead of those being chosen by smokers wanting to quit, smokers may opt for ENDS/ENNDS and HTPs instead. Now that ENDS/ENNDS regulation is becoming more common, the tobacco industry is actively countering attempts to incorporate ENDS/ENNDS into existing tobacco legislation. 66 67WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Brazil marks singular achievement in tobacco control ■ Brazil’s efforts and commitment to tobacco control began in 1981 when the ministry of Health created the Commission for the Study of the Consequences of Tobacco. ■ In 1988, the Constitution determined that tobacco advertising would be subject to legal restrictions and would contain warnings. ■ In 1999, a National Commission on Tobacco Control was created to support the country’s role in negotiating the first global health treaty (under the auspices of WHO) that would later become WHO FCTC. Brazil was also elected to chair the treaty’s Intergovernmental Negotiating Body during the negotiations. ■ In 2003 Brazil was among the first countries to sign the treaty, and ratified it in November 2005 despite being a developing country and a major tobacco producer. ■ In 2003 the country’s National Commission for FCTC Implementation (CONICQ) was established, with the minister of Health serving as the chair. ■ In 2018, Brazil ratified the Protocol to Eliminate Illicit Trade in Tobacco Products which will contribute to protecting the gains and maximize the impact of these very cost-effective tobacco control tools, such as raising tobacco taxes. History of tobacco control in Brazil Tobacco use in Brazil is declining Protect people from tobacco smoke ■ Brazil prohibited smoking in enclosed public and enclosed work places with an exception for designated smoking rooms (DSrs) in 1996. In 2011 the law was strengthened to become a complete ban on smoking in enclosed public places, workplaces and public transport, thus fully aligning with article 8 of the WHO FCTC. ■ Brazil was the first country with a population above 100 million to designate all public and work places as smoke free. Offering help to quit tobacco ■ Since the 1990s the National Cancer Institute of Brazil (INCa) has been training health professionals to carry out cessation treatment. In 2001 the ministry of Health also began offering a national toll-free quit line, and currently the quit line number is displayed on the front of smoked tobacco packages. ■ In 2002 tobacco cessation treatment was formally included as part of the Brazilian Public Health System (SuS) making Brazil fully compliant with article 14 of the WHO FCTC in 2002. at first, tobacco cessation treatment was restricted to specialized health care services, but in 2004 the service was expanded to primary health care services. ■ Between 2005 and 2014 more than 800 000 smokers had access to smoking cessation treatment through SuS. Warning about the dangers of tobacco ■ The first warnings, which stated “Health ministry warns: Smoking is harmful to health”, were printed on cigarette packages in Brazil in 1988. This warning was updated during the 1990s to eventually warn consumers that smoking causes lung cancer, heart disease and other health conditions. ■ In 2001, Brazil approved the first series of graphic health warnings using images that covered 100% of the back of cigarette packs. On each side of the package the number of the quit line appeared alongside the message: “There are no safe levels for the consumption of these substances.” This law also prohibited the use of wrappers or other features that could obscure the graphic health warnings. ■ Brazil was fully compliant with article 11 of the WHO FCTC in 2003, before the treaty even came into force. ■ In 2004 Brazil launched the second series of graphic health warnings, with images and messages of greater impact that had to be included in the tobacco advertising at point of sale. This law included the following messages: “Sale prohibited to minors under 18 years according to Laws 8.069/1990 and 10.702/2003”, and “This product contains more than 4700 toxins and nicotine that cause physical and psychological dependency. There are no safe levels for the consumption of these substances.” ■ By the time the first WHO report on the global tobacco epidemic was published in 2008, not only was Brazil compliant with article 11 of the FCTC, it was one of only three countries in the world that mandated graphic health warning images to cover 100% of the back of cigarette packs. ■ The third series of warnings was launched in 2008. The images from this series were chosen as most impactful by an INCa (National Cancer Institute) study – the findings of which have been used by several countries in the americas to inform their policy on graphic health warnings. ■ In 2011, warning labels were expanded to include 30% of the front of the package, in addition to 100% of the back of the package. a new series of graphic health warnings was launched in may 2018. Enforcing of bans on tobacco advertising, promotion and sponsorship ■ In 2000, a federal law banned tobacco advertising in mass media such as television, radio, magazines, newspapers, and billboards, while also banning some forms of indirect advertising and promotion. ■ In 2011, the federal law was amended to include the complete ban on advertising at point of sale, as well as the bans on promotional discounts and brand sharing, allowing Brazil to become fully compliant with article 13 of the WHO FCTC. The law however still permits product display at point of sale, with a requirement to display graphic health warnings on display racks. Raising taxes on tobacco ■ Brazilian cigarettes were once the sixth cheapest cigarettes in the world, but tobacco taxes have increased significantly since 2007. By 2011 a minimum price policy was established and tobacco taxes were raised, thereby increasing the tax share as a proportion of the retail price of cigarettes. ■ as of 2018, tobacco taxes represent 82.97% of the retail price of the most sold brand, establishing Brazil as the country with the highest tobacco tax rate of all member States in the region of the americas. ■ Brazil has benefited from subregional forums designed to enable countries to exchange experiences and technical cooperation on tobacco tax. The four countries in the region of the americas that are implementing tobacco taxes at the highest level are all located in South america, making this subregion a leader on using tobacco taxes as a tool to reduce affordability. Cu rr en t ci ga re tt e sm ok in g ra te s (% ) i n Br az il (c ap it al c it ie s) Males aged 18+ Females aged 18+ Both sexes aged 18+ 2007 0 5 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 MPOWER measures in Brazil Tobacco use in Brazil is declining ■ adult smoking prevalence declined from 35% in 1989 to 18.5% in 2008 (92). according to the National Health Survey, smoking prevalence was 14.7% in 2013. Based on the telephone survey on NCDs, adult cigarette smoking decreased in capital cities from 15.6% in 2007 to 10.1% in 2017. ■ Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around 5%, with 19% of boys and 17% of girls experimenting with smoking during their school years, according to PeNSE 2015. Anti-tobacco Campaign by Ministry of Health, Brazil, 2019. 68 69WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Effective tobacco control measures Monitor tobacco use and prevention policies Offer help to quit tobacco use Enforce bans on tobacco advertising, promotion and sponsorship Protect people from tobacco smoke Warn about the dangers of tobacco Raise taxes on tobacco 70 71WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Monitoring is the foundation of understanding and measuring tobacco control efforts monitoring tobacco use and tobacco control programmes is critical to effectively combat the tobacco epidemic and assess the effects in each country of WHO FCTC Monitor tobacco use and prevention policies mONITOrINGmONITOrING THE PrEvaLENCE OF TOBaCCO uSE – HIGHEST aCHIEvING COuNTrIES, 2018 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: armenia, australia, austria, azerbaijan, *Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, Cook Islands, Costa rica, Croatia, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic republic, Latvia, Lebanon, Lithuania, Luxembourg, malaysia, malta, mongolia, myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines, Poland, Portugal, Qatar, republic of Korea, republic of moldova, romania, russian Federation, Serbia, Singapore, Slovakia, Slovenia, Spain, *Suriname, Sweden, Switzerland, Thailand, Turkey, ukraine, united Kingdom, united States of america, uruguay, and viet Nam. * Country newly at the highest level since 31 December 2016. article 20 of the WHO Framework Convention on Tobacco Control states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…”(1) . Almost 40% of the world’s population is covered by strong systems that monitor tobacco use There are 2.8 billion people in 74 countries, or 38% of the world’s population, protected by strong monitoring systems that include recent, representative and periodic surveys for both adults and youth. most of these countries (44) are high-income countries. But despite having adequate resources, 25% of high-income countries still do not complete 5-yearly monitoring of tobacco use within their populations. and while some level of monitoring is happening in all but 27 of the world’s countries, there are still no low-income countries monitoring at best- practice level, even though monitoring can be made more affordable if thoughtfully integrated with health systems strengthening activities. Sustained monitoring of tobacco use is a challenge for low- and middle-income countries There are 35 countries (with a combined population of 2 billion) with recent and representative data on both adults and youth that only need to ensure both surveys are repeated within a 5-year time span to achieve best-practice monitoring level. most of these countries (23) are middle-income, six are high-income and six are low-income. If all 35 closed the gap to meet best-practice level, there would be 4.8 billion people (63% of the world’s population) living in countries that ensure effective monitoring of the tobacco epidemic. Low-incomeMiddle-incomeHigh-income 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) No known data, or no recent data or data that are not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth 44 30 6 23 16 37 6 6 3 12 12 6 and mPOWEr measures. monitoring systems should track tobacco use indicators, including cigarette smoking and other forms of smoked tobacco (e.g. cigar, pipe, bidis, water pipe), smokeless tobacco products (e.g. snus), and other tobacco products such as tobacco vaporizers and heated tobacco products, as well as non-tobacco forms of nicotine use (e.g. e-cigarettes). monitoring should also cover the impact of tobacco control policy interventions (38) and tobacco industry activities (93), as data such as these that are accurate and up-to-date enable appropriate policy implementation, precise measurement of policy impact and adjustment of strategies as needed, all of which greatly increase the likelihood of success (94). 72 73WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 More countries need to monitor all forms of tobacco use as well as electronic nicotine delivery systems Historical data show that after the WHO FCTC came into force in 2005 and monitoring began in 2007, no obvious progress was made until the countries new to monitoring the tobacco epidemic began completing their second round of surveys in 2011–2012. While progress appears to have stagnated since 2014, it is expected that as more recently completed surveys are published, coverage levels in 2016 and 2018 will be revised upwards. numbers of tobacco users remain stubbornly high In total, there are 1.4 billion tobacco users aged 15 years and above worldwide – 1.07 billion smokers and 367 million smokeless tobacco users – a small number of whom use both smoked and smokeless tobacco. This number has declined slightly since 2007 when there were 1.46 billion tobacco users. There are 1.12 billion men currently using tobacco (5 million fewer than in 2007) and 279 million women (58 million fewer than in 2007). Despite three out of four countries having banned sales to minors under the age of 18 years – and another 10 countries having set an even higher age limit for tobacco purchases – an estimated 24 million children aged 13–15 around the world smoke, and 13 million use smokeless tobacco. Smoking rates are declining in all country income groups Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. People in low-income countries smoke at about half the rate of people in high-income countries, and this ratio has changed little over the period. The relative reduction of the smoking rate in high-income countries was 20%, and in low-income countries was 19%. In middle-income countries, the relative reduction was only 12%. Smoking rates in middle-income countries, where three quarters of the world’s population live, reflect the global average. While smoking rates are declining fastest on average in high-income countries, they collectively still have the highest average smoking rate of all income groups in 2017 (21.6%). During this same decade, smoking among men decreased from 37.1% to 32.7%, and smoking among women decreased from 8.0% to 5.8%. In 2017, smoking rates among women in high-income countries are still the highest of all country income groups (16.4%) – over four times the average rate in low- and middle- income countries for women (3.5%). In contrast, the highest rates among men are seen in middle-income countries (35.3%), which is almost double the average rate in low-income countries for men (20.2%). Tobacco control must be accelerated to avoid future growth in the number of smokers By 2030, when the ultimate success of the Sustainable Development Goals will be measured, the global average smoking rate is expected to have declined to about 16%. In order to see smoking rates fall below 16%, countries need to accelerate their efforts. In high- and middle-income countries, smoking rates are expected to reach around 17% if they remain on their current trajectories. In low-income countries smoking rates are projected to decline to under 10% by 2030, but only if countries with low rates today are vigilant about not getting caught up in the tobacco epidemic. Global projections of smoking among men and women show a stark contrast, with women’s rates projected to decline to around 4% by 2030 while men’s rates are expected to remain high, at 28%. This scenario would mean a future rise in the number of men smoking due to population growth – up from 908 million in 2017 to 913 million in 2030. To prevent this disastrous outcome, urgent action needs to be taken, particularly among men in middle-income countries where the number of smokers could reach 750 million by 2030. PrOGrESS IN mONITOrING (2007–2018) CurrENT TOBaCCO SmOKING PrEvaLENCE amONG aDuLTS, 2007–2017 Note: While the average time between survey data collection and report release is unknown, the experience of this report is that it takes around 4 years to obtain a complete list of national surveys run in a particular year. Therefore, the data for 2016 and 2018 are incomplete. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la ti on p ro te ct ed (b ill io ns ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Low-income countries GlobalMiddle-income countriesHigh-income countries Pr ev al en ce (p er c en t) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 74 75WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Pr ev al en ce (p er c en t) Low-income countries Global Middle-income countries High-income countries The solid line represents the trend as indicated by survey data, the dotted line indicates the projected trend. WHO-ESTImaTED TrEND IN CurrENT SmOKING PrEvaLENCE, aGES 15+ Over the past 2 years several countries in the WHO Eastern mediterranean region have achieved excellent outcomes in monitoring tobacco use. Lebanon and Sudan in particular have overcome significant challenges to complete landmark surveys on the burden of tobacco use among their populations, reversing long-standing deficits in the collection of tobacco use data. In 2017 Lebanon implemented a WHO Stepwise approach to surveillance (STEPS) survey, incorporating Tobacco Questions for Surveys (TQS) to monitor the effects of tobacco policies and the use of tobacco products such as shisha and narghile. The survey included Syrian asylum seekers – a population hard to reach given their unstable and mobile living conditions. It was the first national survey to provide comparable indicators for migrants and the local population, and the results have helped the country evaluate existing policies and recommend changes. meanwhile, Sudan also undertook its first-ever TQS as part of a STEPS survey, planned and conducted in collaboration with the Federal ministry of Health, the Central Bureau of Statistics and WHO. Capturing populations such as those in remote and conflict-affected areas presented a major challenge. To overcome this, data collectors coordinated with the country’s military in order to travel safely. Data derived from the TQS have helped identify specific geographical areas and at-risk populations at which more targeted interventions can be directed. Overcoming challenges to conduct surveys in the Eastern Mediterranean Region Successful noncommunicable disease risk factor surveillance, Indonesia Between 2007 and 2017, smoking rates decreased from a global average of 22.5% to 19.2%, showing a relative reduction of 15% over 10 years. The RISKESDAS team conducting field work in Jakarta, Indonesia, 2018. The STEPS survey team conducting an interview, Sudan, 2018. Tobacco use is the leading cause of preventable death and morbidity in Indonesia, whose National Institute of Health and research and Development (NIHrD) has been monitoring tobacco use and other NCD risk factors since 2004 using the national health survey. In 2007, riset Kesehatan Dasar (rISKESDaS, or “Basic Health research”) was created – an integrated and nationwide population-based survey which complements and is informed by global standards such as WHO’s STEPwise approach and the Global Tobacco Surveillance System, including the Global adult Tobacco Survey. The success of rISKESDaS lies in its comprehensive coverage of all key NCD risk factors, along with its ability to provide reliable estimates at district, provincial and national levels – an important factor given the decentralized nature of health care delivery in Indonesia. Emphasis is placed on completing the survey and releasing the results within a few months, maximizing their timeliness and usefulness. Since the first rISKESDaS in 2007, NIHrD has conducted the survey every 5 years, completing the most recent round in 2018. With 100% domestic funding, its integration with other key health indicators and its value to policy-makers have sustained the initiative over time. rISKESDaS tobacco module collects information on the age of onset tobacco use, tobacco consumption patterns, cessation attempts, exposure to second-hand smoke, and the use of e-cigarettes. The data can be sorted by key socio- and age- demographic characteristics and show that smoking prevalence among those aged 15 years and above has increased from 27% in 1995 to 33.8% in 2018. Knowing how the use of tobacco is changing within the population is essential for planning policies that will most effectively halt the tobacco epidemic. rISKESDaS results have helped central and district governments in evidence- based planning, as well as in monitoring and evaluation. 76 77WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Protect people from tobacco smoke article 8 of the WHO FCTC states: “… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”(1). WHO FCTC article 8 guidelines are intended to assist Parties in meeting their obligations under article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (95). SmOKE-FrEE LEGISLaTIONSmOKE-FrEE ENvIrONmENTS – HIGHEST aCHIEvING COuNTrIES, 2018 Second-hand smoke kills Exposure to second-hand smoke can lead to severe and fatal diseases including cardiovascular disease, respiratory disease, and cancer (96–99). Children and infants are particularly susceptible to second-hand smoke, and at increased risk for respiratory disease, middle ear disease, and sudden infant death syndrome (100–105). Fetuses and pregnant women exposed to second-hand smoke are more at risk of stillbirth, congenital malformations, and lower birth weights (105). There is no safe level of exposure to second-hand smoke and even brief exposure can cause harm (106). almost all non-smokers living with smokers are exposed and are at greater risk of premature deaths and diseases (107). The only way to adequately protect both smokers and non-smokers from second-hand smoke is to fully eliminate indoor smoking (107). To work, smoke-free laws must be comprehensive Smoke-free laws are highly effective in decreasing exposure and enhancing indoor air quality for both smokers and non-smokers (108–110). However, to be sufficient, they must be comprehensive. It is a misconception that smoke-free places with designated smoking rooms protect non-smokers from second-hand smoke. The only intervention shown to fully protect from second-hand smoke is a smoke-free environment that permits no exceptions (111–113). It is important to remind countries that no safe level of exposure to second-hand smoke exists. accommodations for smoking including separate rooms, designated smoking – areas, ventilation systems, air exchanges, and filtration devices – are not protective, and cannot eliminate all second-hand smoke (98, 110, 111). Exceptions dilute the impact of smoke-free laws. Smoke-free laws save lives There is robust evidence that jurisdictions with legislative smoking bans enjoy reduced hospital admissions for acute coronary syndrome and reduced mortality from smoking-related illnesses (111). Smoke-free laws also denormalize smoking, encouraging healthier behaviours such as maintaining smoke-free homes and automobiles (114–116). Establishing smoke-free environments may also encourage smokers to reduce their tobacco use, make a quit attempt, and remain tobacco-free in the long-term (117, 118). Smoke-free laws are popular and do not hurt business Smoke-free laws are not only life- saving but relatively easy to pass and economically and politically feasible to enforce. an increasing number of countries continue to adopt comprehensive smoke-free legislation at national and subnational levels. In spite of the tobacco industry’s assertions to the contrary, the best-designed studies report that smoke- free laws do not have adverse economic consequences for businesses, including the hospitality industry (119–121). When applied, invariably smoke-free laws achieve overwhelming support from the public (122, 123). Only 22% of the world’s population are protected by complete smoking bans in public places, workplaces and public transport Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). There is remarkably little difference among income groups, with around one in three countries in each income group having a comprehensive ban in place. Two in three countries continue to leave their populations vulnerable to the dangers of second-hand smoke through weak or absent smoke-free laws, with 41 high-income, 68 middle-income and 24 low-income countries poorly or completely unprotected. among them, 24 countries (with 372 million people) have no bans at all – 21 of them low- and middle-income countries. The other 109 countries have partial bans that fall short of a complete ban on smoking in public places and workplaces. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice co ntries, 2018 Best practice countries Other countries Not applicable Low-incomeMiddle-incomeHigh-income Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 34 26 3 24 15 Countries, territories and areas with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, argentina, australia, Barbados, *Benin, Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, *Burundi, Cambodia, Canada, Chad, Chile, Colombia, Congo, Costa rica, Ecuador, Egypt, El Salvador, *Gambia, Greece, Guatemala, *Guyana, Honduras, Iran (Islamic republic of), Ireland, Jamaica, Lao People’s Democratic republic, Lebanon, Libya, madagascar, malta, marshall Islands, Namibia, Nauru, Nepal, New Zealand, North macedonia, *Niue, Norway, occupied Palestinian territory, including east Jerusalem, Pakistan, Panama, Papua New Guinea, Peru, romania, russian Federation, Seychelles, Spain, Suriname, *Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, uganda, united Kingdom, uruguay, and venezuela (Bolivarian republic of). 78 79WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN SmOKE-FrEE LEGISLaTION (2007–2018) 2007 2008 2010 2012 2014 2016 2018 N um be r of c ou nt ir es 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 0 1 2 3 4 5 6 7 8 Po pu la ti on p ro te ct ed (b ill io ns ) 0 50 75 100 125 150 175 200 25 It is time for completely smoke-free environments to become the social norm In the past 2 years, seven countries have joined the group of countries providing protection at best-practice level, with all public places completely smoke-free. Five of these countries went from either no law (Burundi, Niue) or a very minimal law covering up to two public places (antigua and Barbuda, Gambia, Tajikistan) to a complete ban covering all public places and workplaces. The other two countries (Benin and Guyana) strengthened moderate laws already in place to reach best-practice level. Four of these seven countries are low-income countries. an additional eight countries upgraded their smoke-free laws but did not reach full coverage. While there has been sustained progress in implementation of smoke-free laws since 2007 when only 10 countries had a complete law, progress among low- and middle-income countries has been particularly dramatic. In those 11 years, 40 low- and middle-income countries (more than one in four) have adopted a complete smoke-free law, while only 12 high-income countries (one in five) have done the same. The population protected globally by smoke-free legislation at best-practice level has increased from 232 million to 1.6 billion since 2007. Comprehensive smoke-free legislation is a popular policy measure There are 11 countries, representing 120 million people, that only need to cover one more place with a smoking ban to join the 62 other countries with a complete smoke- free law: Tonga (universities); Democratic People’s republic of Korea (government facilities); Cook Islands, mauritius, ukraine and Zambia (indoor offices); Senegal (restaurants); Bhutan (cafes, pubs, bars); and Cyprus, Georgia and Hungary (public transport). Fifteen countries, with a combined 1.7 billion people, need only remove the possibility of designated smoking rooms in their laws to achieve best-practice level. Fifteen countries with 1.6 billion people only need to cover two more places with a smoke-free ban to reach best-practice adoption. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only 284 million (in 47 cities) are protected by a comprehensive smoke-free law. Five of these cities (Bandung, Jakarta, medan, Beijing and Hong Kong Sar) are covered by city-level smoke-free laws, ten are covered by state- or province-level smoke-free laws and the remaining 32 are covered by national laws. Instead of waiting for a national policy to be put in place, the remaining 53 of the world’s largest cities not currently protected by a national best-practice policy could move ahead with a city, state or provincial level policy to protect their large populations sooner. Comprehensive smoke-free legislation is in place for over 1.6 billion people in 62 countries (covering 22% of the world’s population). 80 81WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Xi’an city launches its smoke-free regulations at Daming Palace, 2018. A community engagement session to inform people about the harms of tobacco and second- hand smoke using WHO visual resources in the Gambia. Another city goes smoke free in China Public places go smoke-free in Gambia Xi’an has long been one of the most popular tourist destinations in the world, with more than 200 million people visiting the city (population 10 million) each year. In august 2018, with leadership from the municipal Legislative Office and strong support from the Xi’an municipal Government, the city adopted a regulation to ban indoor smoking in all workplaces, on public transport, and in indoor public spaces. Strong support from the health commission, international community, and domestic NGOs helped pass the regulation and protect the millions of citizens and visitors to the city from the harms of second-hand smoke. Extensive public education and awareness campaigns were initiated to promote the new smoke-free regulation and strong enforcement efforts were implemented. The municipal government started a competition among the various government agencies responsible for enforcement to encourage participation in the new regulations and asked them to submit on a monthly basis their enforcement numbers, fines, penalties, training events and communication campaigns. as of april 2019, more than 155 000 venues were inspected, and more than 240 000 yuan in fines and penalties have been collected. For more than a 1000 years – and as the starting point of the Silk road – Xi’an has played a critically important role in the trade and economy of the region. Now its leadership will serve to inspire other cities to focus on the health of their citizens and visitors. The world looks forward to the continued leadership of Xi’an, and a tobacco-free Silk road in the near future. In 2015 Gambia took steps to draft a Tobacco Control act and protect the health of its citizens. Enacted in December 2016 and officially launched in July 2017, the strong leadership of the ministry of Health (supported by WHO) and an effective, multisectoral platform helped facilitate the country’s substantial progress. While previous smoke-free legislation required people not to smoke in public indoor areas, these bans were incomplete, allowing smoking areas or designated smoking rooms in almost all venue types. The new act took a major step forward by removing these exemptions, making the ban complete across all venues. In 2018 a national tobacco control committee was established to facilitate the implementation of the act, which entered into force on 18 July 2018. at the same time civil society was mobilized to increase public and community awareness about the dangers of smoking, particularly in public places. WHO provided technical support and guidance to the ministry of Health, and involved the ministries, finance, justice, basic and secondary education, higher education, information and communication, tourism, trade, industry and employment, foreign affairs, youth and sports, as well as the medical research council and the media. With smoke-free legislation in place it is now important to monitor compliance in all venues and to ensure that the law is enforced to achieve the greatest impact on the health of Gambia’s population. 82 83WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Offer help to quit tobacco use countries that reduced services, five were high-income (Brunei Darussalam, Estonia, Israel, malta and Panama) and one was middle-income (Islamic republic of Iran). Three of the countries (Brunei Darussalam, Israel and Panama) discontinued their toll-free quit line, and the other three discontinued cost-coverage of nicotine replacement therapy (NrT). While progress has been slower in “O” than other mPOWEr measures since 2007, best-practice adoption of cessation services nonetheless increased from 10 countries (5% of the world’s population) in 2007 to 23 countries (32% of the world’s population) in 2018 – meaning 2 billion more people are now protected by this measure. The population offered best-practice cessation services in 2018 is six times what it was in 2007 (when it was only 401 million people). There are 67 countries – home to 2.1 billion people – whose package of cessation support is missing only one element to achieve best-practice implementation: (i) a national toll-free quit line; (ii) cost-coverage of NrT; or (iii) cost-coverage of cessation services in clinical settings or in the community. Of these 67 countries, 28 need to add a national toll-free quit line in order to bring comprehensive tobacco cessation support to an additional 805 million people, while 38 need to offer cost-covered TOBaCCO DEPENDENCE TrEaTmENT Low-incomeMiddle-incomeHigh-income Data not reported None NRT and/or some cessation services, neither cost-covered NRT and/or some cessation services, at least one of which is cost-covered National quit line, and both NRT and some cessation services cost-covered 6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 16 1 1 14 7 11 5 16 37 Just over 30% of the world’s population are covered by comprehensive cessation services as of 2018, comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. The number of countries adopting comprehensive tobacco cessation measures lags behind the other mPOWEr measures, with only 16 high-income countries, six middle- income countries and one low-income country (Senegal) offering comprehensive cessation support. Globally, almost all high-income countries make cessation services available and 90% also offer at least partial cost coverage of these services. The majority of middle-income countries (72%) do the same, while only 24% of low-income countries offer any cost-coverage for services. There are 24 countries that provide no cessation support at all. These numbers show that while great work has begun, there is still much more to be done. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Best practice countries Other countries Not applicable TOBaCCO DEPENDENCE TrEaTmENT – HIGHEST aCHIEvING COuNTrIES, 2018 Demand is building for cessation services – it is time to deliver The proportion of the world’s population covered by comprehensive cessation services decreased by 1% between 2016 and 2018. On a positive note, four countries with a combined population of 60 million (Czechia, Saudi arabia, Slovakia, Sweden) began offering comprehensive cessation services in the past 2 years. Disappointingly, however, the number of people protected by these countries newly adopting best practice is offset by six countries – representing 97 million people – that dropped out of the best-practice group in the same period. Of these Countries with the highest level of achievement: australia, Brazil, Canada, *Czechia, Denmark, El Salvador, India, Ireland, Jamaica, Kuwait, Luxembourg, mexico, Netherlands, New Zealand, republic of Korea, *Saudi arabia, Senegal, Singapore, *Slovakia, *Sweden, Turkey, united arab Emirates, and united States of america. * Country newly at the highest level since 31 December 2016. Comprehensive tobacco cessation services are in place for 2.4 billion people in 23 countries – 32% of the world’s population. 84 85WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 NrTs to cover an additional 1.3 billion people and one (Côte d’Ivoire) needs to begin cost-covering one or more of its cessation services in clinical settings or the community so that an additional 25 million people will be covered. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, only half (255 million in 49 cities) have access to appropriate cessation support. Of these cities, two have city-level policies in place (Hong Kong Sar and London), and the other 47 have national-level policies. Instead of waiting for a national policy to provide cessation support, the remaining 51 could move ahead with a city, state or provincial level policy to more immediately protect their large populations. Prioritize three key tobacco cessation interventions at a minimum, three cessation interventions should be included in a comprehensive tobacco control programme: brief cessation advice in primary care settings, national toll-free quit lines, and pharmacological therapy that at the very least includes NrT. Tobacco cessation support in primary care facilities middle-income countries have made notable progress in providing tobacco cessation support in at least some primary care settings since 2007. The population covered with cost-covered cessation support in at least some primary care facilities has increased from 23% to 75%, with most of this increase occurring in middle-income countries. There has been little to no progress in high-income countries since 2012 and very little progress in low-income countries at all since to 2007. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities. national toll-free quit line Only a third of countries have a national toll-free quit line in place – a situation that has changed very little since 2016. middle-income countries have made the most progress in establishing national toll-free quit lines, with the proportion of middle-income countries covered rising from 10% in 2007 to 33% in 2017. National toll-free quit lines were the only cessation intervention that saw an increase in adoption since 2016. TOBaCCO CESSaTION SuPPOrT IN aT LEaST SOmE PrImary CarE FaCILITIES (2007–2018) NaTIONaL TOLL-FrEE QuIT LINE (2007–2018)PrOGrESS IN TOBaCCO DEPENDENCE TrEaTmENT (2007–2018) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n w it h ac ce ss t o co st -c ov er ed ce ss at io n su pp or t in p ri m ar y he al th c ar e se tt in gs 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 High-income Middle-income Low-income % o f w or ld p op ul at io n co ve re d by a na ti on al t ol l-f re e qu it li ne 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 86 87WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Ten countries introduced a quit line in the last 2 years: Belarus, Bulgaria, Czechia, Latvia, republic of moldova, Saudi arabia, Slovakia, Timor-Leste, Turkmenistan, and ukraine. Five countries (Brunei Darussalam, Cambodia, Israel, Norway and Panama) discontinued their quit lines after 2016, leaving a net increase of five countries. nicotine replacement therapy must be affordable Globally, while more than two thirds of the world’s countries make NrTs available, less than one third either partially or fully cover the costs. Disappointingly, the number of countries providing NrTs has decreased since 2016 and only 45 countries have placed NrT on their essential drugs list. affordability of NrT is a key issue. Countries that do not (or only partially) cover NrT costs rely on tobacco users to finance this cessation tool out-of- pocket. an analysis of prices from 56 countries shows that (on average) the least expensive NrT option, adjusted for purchasing power parity, costs 40% less than the cost of smoking one pack a day of the cheapest cigarette brand over the same period of time. This means that, at least for heavy smokers, even paying for NrT out-of-pocket (no costs covered) while attempting to quit is likely to be less expensive than continuing to smoke. The price difference between NrTs and the cheapest brand of cigarettes is greatest in high-income countries, where it is significantly cheaper to purchase an 8-week course of nicotine replacement therapy compared to 56 packs of the cheapest cigarettes. Even in middle-income countries included in the analysis, where the cost of NrT is significantly higher, overall cost comparisons show the prices are similar over the same period of time. In countries that have some form of cost-coverage for NrTs, the cost of the cheapest NrT is almost 20% less, suggesting the presumably larger demand for these products helps reduce out- of-pocket costs. It should be noted this same situation may not be the case in low- and lower-middle-income countries, where NrTs are likely to be relatively more expensive and cigarettes much cheaper. While far from being universally accessible, using NrT as a cessation tool is relatively affordable compared to the cost of smoking. Cost-coverage of NrTs is an important factor for governments to consider, particularly when trying to expand access to proven and effective cessation tools. NrT has the best balance of effectiveness, cost and safety. as a result, two forms of NrT (nicotine gum and nicotine patch) have been added to WHO model List of Essential medicines since 2009 (see: https://www.who.int/medicines/ publications/essentialmedicines/en/). The model list presents a list of drugs that are essential to health systems. Countries should consider adding NrT to their national essential drug lists. Policies and capacity for tobacco cessation must improve WHO FCTC article 14 guidelines recommend the implementation of four specific infrastructure elements in order to promote tobacco cessation and provide effective tobacco dependence treatment: n A national cessation strategy: among the countries for which there are data, almost 40% (73 out of 187) have national cessation strategies, ranging from 60% of high-income countries to 18% of low-income countries. n national tobacco cessation guidelines: an assessment was made of countries’ national tobacco cessation guidelines and clinical guidelines for treating tuberculosis, cancer, cardiovascular disease, diabetes, chronic obstructive pulmonary disease, reproductive health, mental health and oral health problems. This revealed that 82 countries (42% globally) have national tobacco cessation guidelines; and 136 countries (73% of those that submitted a questionnaire) have at least one disease-specific clinical guideline which includes cessation. Two thirds of these countries are low- and middle-income countries. n Training capacity: a total of 50 countries reported regularly training primary care providers in brief advice (which should be integrated into primary care disease prevention and control programmes) and/or providing at least one form of cessation training as part of medical, nursing or dental curricula. avEraGE PrICE OF THE LEaST EXPENSIvE NrT OPTION COmParED WITH SmOKING THE CHEaPEST BraND POLICIES aND STruCTuraL CaPaCITy FOr NaTIONaL TOBaCCO CESSaTION SuPPOrT All countries Cheapest NRT Option Cost of Smoking 20 Sticks per day (Cheapest Brand) PPP $196.51 PPP $171.65 PPP $389.86 PPP $244.92 PPP $222.11 PPP $332.94 High-income countries Middle-income countries M Monitoring 0 50 100 150 200 250 300 350 400 450 In te rn at io na l $ (P PP -a dj us te d) n All medical notes include information about tobacco use: Including tobacco use status in medical records helps to routinely identify tobacco users and advise them to quit. Of all the infrastructure and systems components examined, this was the least implemented. Tobacco use was reported in routine medical records in only 35 countries. While it is recommended that tobacco cessation measures are implemented synergistically with other tobacco control initiatives, only 45 countries reported integrating quit line information into mass media campaigns or placing quit line numbers on the graphic health warnings on tobacco products. Of the countries that have a national toll-free quit line, no low-income countries had incorporated quit line numbers on graphic health warnings or in mass media campaigns. National Cessation Strategy Cessation Clinical guidelines Disease specific guidelines Tobacco use in Medical Quit line on warnings or campaigns Training for cessation capacity Middle-income High-income Low-income 0 20 40 60 80 100 120 140 160 N um be r of c ou nt ri es 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 88 89WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 India is the second largest consumer of tobacco products, with more than 200 million users of smokeless forms of tobacco (SLT) and 276 million consumers of tobacco overall. In 2017 a Global adult Tobacco Survey (GaTS2) found 38.5% of adult smokers and 33.2% of adult SLT users in India had attempted to quit. The government recognized the demand for cost-effective and accessible cessation services and adopted a multi-pronged strategy to reach out to tobacco users across rural and urban India. In addition to the integration of brief advice in primary care, a toll-free quit line and a national framework for joint TB-Tobacco activities, India has leveraged technological solutions to increase access. The National Tobacco Control Programme and the ministry of Health and Family Welfare, with support from WHO and the International Telecommunication union’s “Be He@lthy, Be mobile” initiative, implemented the mCessation programme. Part of the “Digital India” initiative, it uses two-way messaging between the individual seeking to quit and programme specialists, providing dynamic support for those who wish to quit. a unique feature of the programme allows users who want to quit to register by giving a missed call to a dedicated national number, or by registering at http://www.nhp.gov. in/quit-tobacco. The government has recently released version 2 of the mTobaccoCessation platform, which is capable of delivering the content through SmS or interactive voice response in 12 languages. The programme’s progress is monitored in real time through an online dashboard that details the number of registrations, disaggregated by factors such as gender, geography, and tobacco use type. To date, the programme has over 2.1 million self-registered users. an evaluation conducted by the ministry of Health and Family Welfare found an average quit rate of 7% for both smokers and smokeless tobacco users 6 months after enrollment. When 12 000 participants in the programme were asked about their tobacco use, more than 19% said they had abstained over the past 30 days. India has also launched a second national mHealth programme, mDiabetes, for the prevention and management of diabetes. Both programmes have been integrated into the national NCD screening initiative under the national health protection scheme, “ayushman Bharat.” Since 2005, the republic of Korea has promoted cessation services in all public health centres across the country. From June 2017 to June 2018 alone, 357 936 smokers were given brief advice to quit, and 70 833 (19.8%) of them had not smoked for 6 months after their quit date. In 2006 a national toll-free quit line was launched to strengthen and support the national cessation programme. The quit line is available 13 hours a day on weekdays, and 9 hours a day on weekends, and provides registered users with free counseling sessions for 1 year. Of the 17 752 tobacco smokers who received at least one telephone counseling session between 2017 and 2018, 3368 (19%) had not smoked for 6 months after their quit date. In 2015 the National Health Insurance Service started to cover the cost of tobacco cessation consultation and cessation drug fees in hospitals and clinics across the country. an outreach service, known as “Quit Bus” was introduced to help and encourage socially marginalized smokers, such as women and out-of-school youth, to quit. regional smoking cessation centres were established to provide free intensive treatment to heavy smokers. The expansion of services led to an increase in the number of people registering with national smoking cessation services from 439 971 in 2014 to 861 086 in 2017. The comprehensive national smoking cessation services contributed to a significant decline in the smoking rate among adult males, from 66.3% in 1998 to an historic low of 38.1% in 2017. The earmarking of tobacco tax revenue for quit services and providing cessation services in conjunction with other tobacco control initiatives are key factors that contributed to this success. When Senegal adopted its Tobacco Control act in 2014, the Health Commission of the country’s National assembly affirmed that tobacco cessation was a national priority and that comprehensive smoking cessation support would be established to help smokers quit. at the time, the Chair of the Health Commission, awa Dia Thiam, told members of Parliament: “measures must be taken to support smokers who want to quit smoking and help them through the very difficult preliminary phase.” Since then the ministry of Health and Social action has created a national toll-free quit line offering trained counselors who are able to give advice on smoking cessation and advise callers about the various treatments available in Senegal to help them quit. During the first 4 months, 4068 calls were received by the quit line. more recently, the National Tobacco Control Program, which is responsible for coordinating tobacco control policy, has developed a National Tobacco Control Strategic Plan 2018–2022, which details the cessation services available. India successfully implements mCessation The Republic of Korea offers comprehensive help to quit smoking Smoking cessation counselling in a mobile clinic known as the Quit Bus, Republic of Korea. Quit line featured on cigarette packs, Senegal. Ecuador ratified the WHO FCTC in 2006, and despite advances in tobacco control, according to the Institute of Health metrics and Evaluation (see https://vizhub.healthdata.org/gbd-compare/), an Ecuadorian citizen dies from tobacco every 2 hours1. Providing tobacco cessation support via the country’s health system is still a challenge – and one that can be met by encouraging collaboration with other sectors. In this context, in 2018 Ecuador took steps to integrate brief tobacco interventions into primary care, aligning with their “médico del Barrio” strategy (Neighborhood Doctor strategy)2. as part of this intervention, the Ecuadorian ministry of Health has established a national training network, linking together training institutions responsible for on-the-job training of primary care providers and asking WHO to strengthen the capacity of their national training network on tobacco cessation. In response, WHO, PaHO and the European respiratory Society (which provided financial support) conducted a joint train-the-trainer tobacco cessation workshop for 55 national trainers in January 2018. In march 2018, integration of brief tobacco interventions into primary care began in Pichincha, Guayas, azuay and Cañar provinces. about 120 primary care providers were trained on brief tobacco interventions and have since been routinely identifying tobacco users and advising them to quit. The results of the project have been very encouraging. From mid-march to mid-November 2018, 3916 tobacco users were identified and given advice on quitting. among the 2069 patients who completed a follow-up at 4 months, the 7-day self-reported abstinence rate was 57.2%, and of the 968 who completed a 6-month follow-up assessment, the self- reported abstinence rate was 48.9%. Based on these results, Ecuador plans to expand tobacco cessation integration to more provinces. Integrating brief tobacco interventions into primary care, Ecuador 1 The data result displays a mean estimate expressed in the raw number of 5372 deaths and a 95% range of uncertainty interval from 4669 to 6143 deaths. 2 “medico del Barrio” is an advanced primary health care strategy developed and implemented by the Government of Ecuador, whose purpose is to provide health care services to vulnerable and priority populations via patient recruitment and screening. This is done through home visits by health teams consisting of a general practitioner, a nurse, a primary health care worker, and the support of a community and family physician and/or a general comprehensive physician working at the first level of care. A man receives brief advice about quitting tobacco, Ecuador. mCessation messages received in English and Hindi in India. 90 91WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Warn about the dangers of tobacco high-income countries, 45% of middle- income countries and 15% of low-income countries. Only 10% of countries (five high-income, nine middle-income and seven low-income) have not adopted any warning labels, and 22 others (11%) have issued warnings that cover less than 30% of the principal package display areas (below the minimum required by the WHO FCTC). One in three low-income countries has no warning, or a warning that is smaller than required. article 11 of the WHO FCTC states: “Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”(1). WHO FCTC article 11 guidelines are intended to assist Parties in meeting their obligations under article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (95). HEaLTH WarNING LaBELS – HIGHEST aCHIEvING COuNTrIES, 2018 Health warning labels Health warnings provide critical information about the harms of tobacco use Despite the overwhelming evidence- base on the harms of tobacco, many tobacco users still do not fully appreciate the dangers they expose themselves and others to by consuming tobacco (124). Consumers have a right to be warned about the health impacts of the products they purchase and consume, and this includes sufficient and accurate information regarding the risks of tobacco use (124–126). Graphic health warnings providing accurate information about the risks associated with tobacco use can help stimulate tobacco users to reduce their consumption and quit (127, 128). Effective health warnings communicate the risks of consuming tobacco as well as the risk to others of exposure to second-hand smoke (129). There is significant evidence that accurate, prominent warnings prompt tobacco users to think about quitting, and can result in decreased tobacco use (130, 131). Health warnings on tobacco packaging are effective Graphic health warnings on tobacco product packages reliably reach tobacco users each time they use the products (132). at the same time, applying warning labels to packaging is at relatively low expense to governments (132). Graphic health warnings are well-supported by the public – more so than most other tobacco control measures (129, 133). Warnings should refer to specific health effects related to tobacco use. They are most effective when they are pictorial, graphic, comprehensive, and strongly worded (134, 135). It is important that the warning is large, covering at least half of a tobacco package’s surface (front and back) (132). To sustain their impact, labels should be rotated on a regular basis (136). Companies use packaging to manipulate users’ perceptions of a tobacco product’s taste, strength, and health impacts, in essence turning packaging into a product characteristic (137). Terms suggesting reduced health risks including “light”, “ultra-light”, and “low tar” are deceptive and should be prohibited (130). However, removing misleading descriptors may not be sufficient to decrease the misperceptions of reduced risk associated with these cigarette types (138, 139). Over half of the world’s population are exposed to large and effective graphic health warnings Strong graphic pack warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). more people are protected by this mPOWEr measure than any other, with 47% of countries implementing graphic pack warning requirements at the highest level: 65% of 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: argentina, armenia, australia, austria, Bangladesh, *Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, *Cameroon, Canada, Chad, Chile, Costa rica, *Croatia, *Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, Fiji, Finland, France, *Georgia, Germany, Greece, *Guyana, *Honduras, Hungary, India, Iran (Islamic republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic republic, Latvia, Lithuania, *Luxembourg, madagascar, malaysia, malta, mauritius, mexico, mongolia, Namibia, Nepal, Netherlands, New Zealand, *Pakistan, Panama, Peru, Philippines, Poland, Portugal, republic of moldova, romania, russian Federation, *Saint Lucia, Samoa, *Saudi arabia, Senegal, Seychelles, Singapore, Slovakia, *Slovenia, Solomon Islands, *Spain, Sri Lanka, Suriname, Sweden, Thailand, *Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, ukraine, united Kingdom, uruguay, vanuatu, venezuela (Bolivarian republic of), and viet Nam. * Country newly at the highest level since 31 December 2016. 92 93WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Four out of five low-income countries do not mandate sufficient warnings on packs In the past 2 years, 14 additional countries, with 4% of the world’s population, have joined the 77 countries that required large graphic warning labels on tobacco products. Seven were high- income countries and the other seven were middle-income. Of the 14 countries, two (Barbados and St Lucia) went from no required health warnings at all to a complete law covering at least 50% of the pack with a graphic health warning, and the other 12 strengthened existing laws to meet best-practice level. No low-income countries achieved complete adoption of graphic warning laws in the past 2 years, meaning four out of five low-income countries are still not mandating sufficient warnings on packs. Strong graphic health warnings are in place for almost half of all countries and more than half of the global population Compared to 2007, when only nine countries (5% of the world’s population) had large graphic pack warnings on cigarettes, there are now 91 countries (52% of the world’s population) with comprehensive graphic pack warning requirements. This means 82 countries have taken action to adopt laws that require strong graphic health warnings on tobacco products since 2007. The 28 member States of the European union (Eu) are large contributors to this increase, since all of them have incorporated the requirements for large graphic health warnings required by the 2014 Eu warning label directive into their national laws (23 countries had done so by 2016 and the remaining five by 2018). In addition, India reached best-practice level in 2016, adding 1.35 billion people to the total population coverage. Of all mPOWEr measures, this one has seen the most progress since 2007 both in terms of countries acting and population covered by a best-practice policy. Eight countries, with 384 million people, need only raise the pack coverage by 20% or less to meet all best-practice criteria for large graphic pack warnings. an additional 15 countries have mandated large warnings (at least 50% of the pack) and need only add one criterion to achieve best practice. Eight of these 15 countries, representing 157 million people, need only mandate that strong graphic health warnings appear on each package and any outside packaging used in the retail sale, and six countries, with 360 million people, need only add a requirement for a graphic image (instead of text only) – albania, Cook Islands, Niger, Togo, Tonga and the united States of america. The remaining member of this group, Gabon, with 2 million people, only needs to require a specification of font style, font size and colour for pack warning requirements to reach best-practice level. Of the 505 million people (6.6% of the world’s population) who live in one of the world’s 100 largest cities, two thirds (339 million) live in one of the 62 cities protected by graphic pack warnings containing all appropriate characteristics. These cities are all covered by a law passed at the national level, apart from Hong Kong Sar, which has a city-level law in place. HEaLTH WarNING LaBELS PrOGrESS IN HEaLTH WarNING LaBELS (2007–2018) Low-incomeMiddle-incomeHigh-income Data not reported No warning or small warnings Medium size warnings missing some or many appropriate characteristics OR large warnings missing many appropriate characteristics Medium size warnings with all appropriate characteris- tics OR large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics 39 47 12 24 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 Po pu la tio n pr ot ec te d (b ill io ns ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 Strong graphic health warnings are in place for almost 3.9 billion people in 91 countries – over half of the global population (52%). 94 95WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Plain packaging is effective and increases the effectiveness of health warnings Plain packaging (also called standardized packaging) is packaging which restricts or prohibits “the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style” (95). Plain packaging simultaneously reduces the attractiveness of tobacco products, eliminates the effects of tobacco packaging as a form of advertising and promotion, minimizes misleading product descriptor language, and enhances the noticeability and effectiveness of health warnings (140–143). There is evidence that plain packaging reduces misperceptions that some cigarettes are less harmful than others, and decreases both smoking prevalence and smoking behaviours (144). First implemented by australia in 2012, plain packaging has been challenged by the tobacco industry on the basis of protection of trademarks, freedom of commercial expression, protections for trade, and protections for the free movement of goods (145). These challenges have been rejected in the domestic courts of australia, England and Wales, France, and Norway (145). In addition, in June 2018, a World Trade Organization panel ruled against complaints brought by four countries regarding australia’s tobacco packaging law (146). More and more countries require plain packaging of tobacco products In spite of tobacco industry lobbying, several countries are now moving forward with plain packaging. By the end of 2018, 10 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates (australia, France, Hungary, Ireland, New Zealand, Norway, Saudi arabia, Thailand, united Kingdom and uruguay). In addition, Belgium, Canada, Singapore and Turkey have passed plain packaging regulations in 2019. Burkina Faso, Georgia, Israel, romania and Slovenia have passed laws but not regulations and do not yet have implementation dates. Georgia has one of the highest rates of tobacco use in the world. about 33% of the adult population are current smokers (including 57% of men), in addition to 12.6% of 13–15-year- olds. about 11 400 Georgians die every year as a result of tobacco use, and the country loses 2.4% of its annual GDP to tobacco-related deaths and disability. While the first tobacco control law in the country was adopted in 2003, strong interference from the tobacco industry prevented the law from being comprehensive. For more than a decade Georgia’s laws have remained stagnant. However, in 2015 a plan for change began to take shape. The Tobacco Control alliance, with support from several NGOs and funding and strong technical backing from the Campaign for Tobacco Free Kids, began an advocacy campaign, mobilizing and consolidating all local and international players working in tobacco control, health, and human rights. On 17 may 2017 the new law was adopted. The law requires that pictorial health warnings cover at least 65% of the two biggest sides of the packaging of all smoking tobacco products (including cigarettes, cigars, water pipes, heated tobacco etc.). Georgia’s government decreed that the nine most effective pictorial warnings (selected by the ministry of Health based on focus group results) developed in australia and Canada must be used. Packages of smokeless tobacco products must provide written health warnings on 30% of the two biggest sides. Three general graphic health warnings and three additional ones with relevant pictograms are subject to rotation during a year and should be equally distributed on each type of tobacco package. There is no place for complacency however, as ongoing tobacco industry interference continues to undermine tobacco control efforts in Georgia, with the industry successfully delaying the implementation of plain packaging to December 2021. as the success of plain packaging requirements becomes ever-more apparent, more countries, including middle-income countries, are starting to adopt the measure. The following three countries are the first in their respective regions to do so. uruguay continues to lead the Americas In 2018 uruguay continued its role as a leader for the americas, becoming the first country in the region to enact plain packaging requirements for tobacco products. uruguay’s president, Tabaré vàsquez, signed an executive decree mandating plain packaging on 6 august 2018. Only a month later, however, the decree was suspended due to a lawsuit filed by British american Tobacco (BaT). The administrative First Instance Court ruled in favour of BaT because the plain packaging measure had been enacted by an executive decree instead of a law adopted by Parliament. The uruguayan government appealed this decision and on 11 October 2018 the Court of appeal ruled in the government’s favour, although a law would still be necessary to establish plain packaging. a legislative effort was immediately launched that month, leading to the adoption of Law 19.723 on 12 December 2018 and a detailed decree on 29 april 2019, with the law to be implemented for all tobacco products from 22 December 2019. Saudi Arabia introduces plain packaging In late 2018, the Saudi Food and Drug authority (SFDa) issued regulations requiring plain packaging on tobacco products, making Saudi arabia the first country in the Eastern mediterranean region to do so. In preparation for the legislation (which will be fully implemented on 1 January 2020), the SFDa issued a model plain package to all tobacco product manufacturers and importers, specifying the required standard colour and font style, and sample graphic health warnings that must be carried, selected from both the WHO and Eastern mediterranean regional Office’s Graphic Health Warnings database. In alignment with Saudi arabia’s 2030 vision for the promotion of public health, it is expected that this step will contribute to Saudi arabia’s overall tobacco control agenda. Thailand is the first upper-middle-income country to introduce plain packaging In December 2018, Thailand made history when it became the first country anywhere in asia (and the first upper-middle- income country in the world) to require plain packaging – a law that will be fully implemented by 9 September 2019. “Plain packaging is a landmark measure for tobacco control that will help reduce the use of these deadly products in Thailand,” said Dr Daniel a Kertesz, WHO representative to Thailand. The new measure complements earlier legislation requiring 85% of the surface of tobacco packs to show graphic warnings of the adverse effects of smoking on health. Georgia adopts new law on health warnings Plain packaging spreads across the globe Plain packaging guidelines, Uruguay. The Georgian parliament votes for a tobacco control bill, 2017. 96 97WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Anti-tobacco mass media campaigns article 12 of the WHO FCTC states: “Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristic of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles;… [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”(1). WHO FCTC article 12 guidelines are intended to assist Parties in meeting their obligations under article 12 of the WHO FCTC (95). Well-designed anti-tobacco mass media campaigns can reduce tobacco use Well designed, hard hitting anti-tobacco mass media campaigns can reduce tobacco use. There is strong evidence that mass media campaigns increase quit attempts, lower youth initiation rates and reduce second-hand smoke exposure (147–152). mass media anti-tobacco campaigns are commonly used in high- income countries but have been shown to be effective in low-and middle-income countries as well (153). Sustained campaigns are more likely to have a longer-term impact on tobacco use behaviour, but campaigns running for as little as 3 weeks can still have a positive impact (148, 154, 155). Television campaigns using graphic imagery are known to be especially effective in motivating tobacco users to attempt to quit (151, 156). mass media campaigns can be expensive, but they have the potential to quickly and efficiently reach very large populations (151). Including information about what tobacco users can do to quit, such as providing a toll-free quit line number on the products of the mass media campaign, e.g. on the bottom of posters or at the end of television advertisements. Comprehensive tobacco control strategies must include mass media campaigns anti-tobacco mass media campaigns not only create awareness and inform people about the harms of tobacco use and second-hand smoke, they also encourage maSS mEDIa CamPaIGNSaNTI-TOBaCCO maSS mEDIa CamPaIGNS – HIGHEST aCHIEvING COuNTrIES, 2018 Low-incomeMiddle-incomeHigh-income Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign implemented with 1–4 appropriate characteristics National campaign implemented with 5–6 appropriate characteristics, or with 7 characteristics excluding airing on TV and/or National campaign implemented with at least 7 appropriate characteristics including airing on television and/or radio 3 17 2 4 2 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 quitting. as such it is imperative that these campaigns form an important part of any comprehensive tobacco control strategy or programme (156). Governments should develop and deliver messages designed to educate current and potential tobacco users about the dangers of tobacco influence attitudes and beliefs about tobacco use (149). Mass media efforts continue to fall behind Less than a quarter of the world’s population (1.7 billion people) live in a country that has aired at least one national comprehensive anti-tobacco mass media campaign in the past 2 years. Of the 39 countries that ran an anti-tobacco campaign during that time, 19 were high- income, 18 were middle-income and two were low-income countries. almost half of the countries in the world (91) have not run any kind of sustained campaign in the past 2 years, leaving about 19% of the world’s population, and an estimated 220 million tobacco users, unreached by any mass media campaign. People in low-income countries are the least exposed to anti-tobacco mass media: over 60% of the population of low-income countries, living in 24 countries, have not been exposed to any kind of campaign in the past 2 years. The first year for which mass media campaigns were monitored was 2010. Since then, the proportion of the world’s population exposed to a best-practice mass media campaign rose until 2014, when 4.2 billion people lived in countries airing such campaigns. regrettably, by 2018 this number had dropped by more than half, to 1.7 billion people. In 2015–2016, 42 countries ran campaigns, a higher number of countries than during any other period. most countries that execute campaigns do not repeat the effort every 2 years. Of the 42 countries that ran a best-practice campaign in the period 2014-2016, 33 ran another campaign in the recent period, but only 22 of these were also best-practice campaigns. Of the 91 countries that ran no campaign at all in the last two years, 20 had previous experience running a best- practice campaign. Of the 14 countries that consistently ran campaigns in all of the five periods assessed (2009–2010, 2011–2012, 2013–2014, 2015–2016 and 2017–2018) only four (australia, Turkey, united Kingdom and viet Nam) maintained best-practice implementation for each campaign. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Best practice countries Other countries Not applicable Countries with the highest level of achievement: australia, austria, *Belarus, *Brazil, *Brunei Darussalam, Costa rica, *Cyprus, El Salvador, Estonia, Fiji, *France, *Georgia, *Germany, Indonesia, *Iraq, Ireland, Italy, Jordan, *Luxembourg, *myanmar, New Zealand, Norway, Pakistan, *Panama, *Qatar, republic of Korea, republic of moldova, *Saint Lucia, *Senegal, Seychelles, Switzerland, *Timor-Leste, *Togo, Tonga, Turkey, *Turkmenistan, united Kingdom, united States of america, and viet Nam. * Country newly at the highest level since 31 December 2016. 98 99WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 PrOGrESS IN aNTI-TOBaCCO maSS mEDIa CamPaIGNS (2010–2018) Note: Data reporting for anti-tobacco mass media campaigns started in 2010. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) a 2014 STEPS survey in myanmar showed 43.2% of the population (62.2% male and 24.1% female) used smokeless tobacco, with 94% reporting the use of smokeless tobaccos containing betel quid. To combat the health risks associated with tobacco use, myanmar implemented its first mass media campaign to increase awareness of the health harms of tobacco use (including betel quid) in September 2017. The national NGO People’s Health Foundation, in collaboration with civil authorities and creative, media and research agencies across myanmar, designed and implemented the campaign. The support of the ministry of Health and Sports and the ministry of Information through free and reduced-cost radio and Tv air time, as well as technical and financial support from vital Strategies (a non-governmental organization), was also instrumental. The 6-week campaign was the first to ever feature stories about actual people harmed by smokeless tobacco in myanmar on Tv, radio and posters. Development followed an evidence-based strategic communication approach that included target audience identification; refinement, pre- testing and production of Public Service annoucements; the use of public and private media (Tv, radio); and post-campaign assessment of the reach and impact. mass media campaigns for tobacco control have been recognized as a WHO “best- buy” approach (28). The significant reach of the campaign, covering 48% of the population in 2017 and over 80% during 2018, is encouraging, and an excellent example of how multistakeholder collaboration can create maximum impact at the country level. China is the biggest consumer of tobacco products. Even though progress has been made in advancing tobacco control initiatives, China’s addiction to tobacco remains strong. The tobacco industry continues to unleash large marketing campaigns and is still able to expand its consumer base and successfully acquire a new generation of smokers. Tobacco- related diseases kill 1 million people in China every year and 100 000 non-smokers die from exposure to second-hand smoke. In may 2017, a campaign for a smoke-free next generation harnessed the power of the entertainment industry by teaming up with celebrities and a fashion magazine (based on their appeal to youth and women in particular) to spread the message that choosing a healthy, smoke-free lifestyle is empowering. The campaign was launched during World No Tobacco Day 2017 and exploded on social media, earning 34 million views in just 3 days. It was ranked as the number one social-good hashtag and within its first week had reached more than 120 million social media users, 70% of them under the age of 40. more than 80 million users participated in campaign discussion threads during the week. Within the first 30 days, 184 media outlets covered the campaign in China and the video was displayed on more than 100 LED screens in landmark buildings and sites throughout China. Even Xiamen airlines aired the video in its lounges around China, and in its aircraft. Myanmar launches first-ever mass media anti-tobacco campaign Entertainment industry helps create a smoke-free next generation in China The #stopbetelmyanmar campaign, Myanmar. Less than a quarter of the world’s population live in a country that has aired a national comprehensive anti-tobacco mass media campaign in the past 2 years. The Smoke-Free Next Generation campaign, China. 100 101WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Enforce bans on tobacco advertising, promotion and sponsorship Bans on tobacco advertising, promotion and sponsorship must be comprehensive more than 10 years after the adoption of the Guidelines for implementation of article 13 of the WHO FCTC, the following principle stipulated at its beginning is still relevant today: “It is well documented that tobacco advertising, promotion and sponsorship increase tobacco use and that comprehensive bans on tobacco advertising, promotion and sponsorship decrease tobacco use” (95). Every year the tobacco industry spends billions of dollars on advertising, article 13 of the WHO FCTC states: “... [a] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with article 21”(1). WHO FCTC article 13 guidelines are intended to assist Parties in meeting their obligations under article 13 of the WHO-FCTC (95). Bans are effective at reducing tobacco use Evidence from across the world indicates that comprehensive bans are effective in reducing tobacco sales and tobacco consumption (164–167). The impact of TaPS bans may be even more dramatic in low- and middle-income countries than in high-income countries (167). TaPS bans are recognized as a key policy measure as they comprise one of only two provisions in the WHO FCTC that impose a mandatory timeframe for implementation (the other one being article 11 of the Convention). Bans must be comprehensive and well-enforced TaPS bans should cover all TaPS activities including both direct and indirect varieties of promotion. Direct forms of advertising include among others television, radio, print publications and billboards, while indirect forms of advertising include among others brand stretching, free distribution, price discounts, point of sale product displays, and sponsorships including corporate social responsibility programmes (168). Point of sale displays “normalize” the products, act as a prompt to smoke, encourage impulse purchases, interfere with quitting, and increase the susceptibility of children and young people to try the product (169–174). When bans are not comprehensive, tobacco companies exploit legal loopholes or simply shift their investments to forms of promotion that are not banned (164, 175, 176). When tobacco companies make financial or in-kind contributions to any other entity for deserving or socially responsible causes such contributions fall within the definition of tobacco sponsorship under article 1(g) of the Convention and should therefore be banned (168). Corporate social responsibility activities are typically employed to convince governments to delay and refrain from implementing 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Best practice countries Other countries Not applicable ENFOrCE BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP – HIGHEST aCHIEvING COuNTrIES, 2018 Countries with the highest level of achievement: afghanistan, albania, *antigua and Barbuda, *azerbaijan, Bahrain, *Benin, Brazil, Chad, Colombia, *Congo, *Democratic republic of the Congo, Djibouti, Eritrea, *Gambia, Ghana, Guinea, *Guyana, Iran (Islamic republic of), Kenya, Kiribati, Kuwait, Libya, madagascar, maldives, mauritius, mongolia, Nepal, Niger, Nigeria, *Niue, Panama, Qatar, republic of moldova, russian Federation, *Saudi arabia, Senegal, Seychelles, *Slove- nia, Spain, Suriname, Togo, Turkey, Tuvalu, uganda, united arab Emirates, uruguay, vanuatu, and yemen. * Country newly at the highest level since 31 December 2016. promotion, and sponsorship (TaPS) activities to promote their tobacco products and increase tobacco sales (157). Despite tobacco companies’ insistence that advertising only increases their market share at the expense of competitors, there is longstanding and consistent evidence of a causal relationship between TaPS activities and increased or sustained tobacco use through both the effective recruitment of new tobacco users or by discouraging tobacco users from quitting (148, 158, 159). Tobacco companies employ a combination of marketing techniques to target different groups. TaPS activities are tailored to specific populations through new products that circumvent regulations and maintain social acceptability (160). youth and women are especially targeted in low- and middle-income countries (161). Exposure to tobacco advertising and promotion increases the likelihood that adolescents will start to use tobacco which may lead to a higher prevalence of adult tobacco users in the future (159, 162, 163). Promotional and sponsorship activities are also effective at influencing businesses that may benefit from the billions of dollars that the tobacco industry invests in TaPS. To counter this, comprehensive bans in all TaPS activities are needed as a key tobacco control strategy (164). More low-income countries have adopted a TAPS ban than any other MPOWER measure. 102 103WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TAPS ban should apply to new media Tobacco companies now frequently utilize novel media platforms for TaPS activities such as social media sites and mobile phone applications (178). On a wide variety of social media platforms, influencers, spokespeople, and brand- sponsored contests are used to promote tobacco products (178, 179). The enormous growth in communications technology and use of Internet-based mobile phones has made it essential to keep a check on tobacco advertising and promotion on platforms such as Instagram, youTube, Facebook etc. Children and adolescents are particularly exposed to these platforms (180). Legislation banning TaPS may not necessarily include a ban on advertisements on the Internet and therefore ensuring that bans are inclusive of Internet-based media is crucial (181, 182). In some cases enforcing TaPS bans on social media sites may require legislation to be implemented across borders and for this reason countries will need to cooperate and coordinate efforts (179). More countries than ever are adopting complete bans on tobacco advertising, promotion and sponsorship Banning TaPS remains an under-adopted measure, with only 18% of the world’s population, in 48 countries, covered by a comprehensive ban. at the same time, there are 44 countries (11 high-income, 21 middle-income, and 12 low-income countries) that have not adopted any TaPS bans to date. Interestingly, more low-income countries have adopted a TaPS ban than any other mPOWEr measure, with 14 low- income countries – or 40% – having comprehensive TaPS bans in place. By contrast, under 20% of high-income countries (11) have achieved this best- practice level. More low-income countries than high-income countries completely ban TAPS In the past 2 years, 10 more countries have banned all forms of direct and indirect advertising, raising the global population covered at best-practice level by 150 million, to 1.3 billion people. Three of these countries were low-income countries (Benin, Democratic republic of the Congo and Gambia); four were middle-income countries (azerbaijan, Congo, Guyana and Niue) and three were high-income countries (antigua and Barbuda, Saudi arabia and Slovenia). adoption of complete TaPS bans has steadily increased over the years, from seven countries in 2007 to 48 countries (one in four) in 2018, an increase of tobacco control programmes and should be included in TaPS bans (174). The tobacco industry attempts to avoid regulation by adopting weak voluntary advertising codes, discrediting the evidence base for restrictions, and using both lobbyists and litigation to avoid bans (148, 165). However, limited bans have little or no effect (148, 164, 177). For bans to be effective, they must be comprehensive. Legislation should use clear, uncomplicated language and unambiguous definitions, and should avoid providing lists of prohibited activities that are, or could be understood to be, exhaustive (167). moreover, legislation must be coupled with strong enforcement and monitoring, with high financial penalties for violations (95). BaNS ON aDvErTISING, PrOmOTION aND SPONSOrSHIP PrOGrESS IN BaNS ON TOBaCCO aDvErTISING, PrOmOTION aND SPONSOrSHIP (2007–2018) 41 countries. Low- and middle-income countries have been leaders in adopting strong TaPS bans throughout the years. In 2007, all seven best-practice countries were low- and middle-income countries (albania, Djibouti, Eritrea, Islamic republic of Iran, Kenya, madagascar and Niger). at any point in time there has always been more low-income countries than high- income countries with a complete TaPS ban. There are only 44 countries that have not adopted any TAPS bans Thirty countries, with 2.1 billion people, are only one provision away from a complete advertising ban. Nine need only to ban brand-stretching (Bhutan, Croatia, Finland, France, Georgia, Lithuania, Sri Lanka, Thailand and Turkmenistan). Seven need only to ban advertising of tobacco products at point of sale (argentina, Cook Islands, India, mali, montenegro, Netherlands and South africa). Seven need only to ban industry sponsorship (Egypt, Iceland, New Zealand, Sudan, Syrian arab republic, united Kingdom and viet Nam). Four need only ban promotional discounts (Cyprus, Ethiopia, Lebanon and Papua New Guinea). Norway need only ban brand-sharing, Tonga need only ban the appearance of tobacco products or brands in Tv and/or films, and occupied Palestinian territory, including east Jerusalem, need only ban the free distribution of tobacco products. almost a quarter of the 505 million people (125 million) who live in 26 of the world’s 100 largest cities are protected completely from exposure to TaPS by national legislation. In all 26 cities, bans on TaPS operate at national level. The other 74 cities are not currently protected by a national TaPS ban, but could move ahead with city, state, or provincial level laws and thereby protect a combined 380 million more people. Low-incomeMiddle-incomeHigh-income Data not reported Complete absence of ban, or ban that does not cover national TV, radio and print media Ban on national TV, radio and print media only Ban on national TV, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by complete subnational bans) 11 37 11 23 58 21 14 8 12 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 104 105WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The republic of the Congo, a Central african country straddling the Equator, ratified the WHO FCTC in February 2007. It entered into force in may 2007. as part of the implementation of article 13, the country banned some but not all forms of TaPS and its products. This initiative was reinforced on 4 July 2012 by the adoption and promulgation of the law on tobacco control, but TaPS bans were still not completed. In June 2018, Congo adopted a decree that expanded the legislation to cover point-of-sale advertising as well as a ban on promotional discounts, brand-stretching and sponsorship, among other TaPS bans. Congo is now one of the 17 countries in the african region that have complete TaPS bans. Compliance data collected in the country for this report show that most of the advertising bans that entered into force in 2006 are well implemented in the country, which is a good omen for the bans recently adopted. With globalization, Niue which is an island country in the South Pacific Ocean, is now far more connected to the rest of the world than ever before, and therefore became more susceptible to tobacco industry marketing. However, Niue, although a Party to the WHO FCTC, had no effective TaPS regulation until recently. Laws to prevent TaPS, particularly at point of sale, are an essential part of protecting the health of the country’s future generations. In 2016, Niue’s government started to work on aligning its tobacco control legislation with the requirements of the Convention. The ministry of Health led public consultations with members of the public sector as well as representatives from civil society organizations and community groups, and in 2018 the Tobacco Control act was passed. The act includes complete TaPS bans. Since the passage of the law, stakeholders have become increasingly aware of the various forms of TaPS, and the new law even prohibits the display of tobacco products at point of sale. In addition to this, the act also bans smoking in public places, workplaces and public transport; bans the import and manufacture of smokeless tobacco, and requires the display of health warnings on packages of smoking tobacco products. In recognition of their outstanding work in tobacco control, Niue’s ministry of Social Services is one of five institutions to receive a WHO World No Tobacco Day 2019 award. The Republic of the Congo tightens TAPS ban Niue passes Tobacco Control Act introducing TAPS ban In 2017 Guyana became only the second country in the English-speaking Caribbean (CarICOm) and WHO region of the americas to enact comprehensive tobacco legislation that adopted complete TaPS bans, alongside a mandate for complete smoke-free environments and a requirement for health warnings on tobacco products. This action propelled Guyana from having zero tobacco control measures to having three “WHO best-buys” (28) adopted at best-practice level. TaPS bans, relative to measures for smoke free environments and graphic health warnings, have not been as widely adopted across the americas region or globally. In the absence of TaPS bans, the tobacco industry has an avenue through which they can continue to recruit tobacco users, making this achievement particularly notable. Guyana’s Tobacco Control act was developed by the ministry of Health, which understood the need to prevent industry influence when enacting new legislation and committed itself to push through a comprehensive initiative that complied with article 13 (E), as well as article 8 (P) and 11 (W). although compliance with the ban has been moderate and compliance at point of sale has been described as low, the ministry of Health has held meetings with stakeholders from the business community, transport services, workers’ unions, and consumer associations, as well as the general public, to strengthen buy-in and compliance. Guyana enacts comprehensive tobacco legislation Awareness raising campaign to introduce bans on tobacco advertising at point of sale, Congo. President of Guyana and the Minister of Health of Guyana receiving the World No Tobacco Day 2018 Award for efforts in tobacco control, including TAPS bans. Government and community representatives provide input into the draft Tobacco Control Bill in Niue, 2017. 106 107WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Raise taxes on tobacco Tobacco taxation is also inexpensive to implement, costing low- and middle- income countries as little as uS$ 0.05 per capita each year to administer (186). Having the potential for massive impact combined with a low implementation cost, tobacco taxation is rightly considered as a highly cost-effective “WHO best-buy” intervention, meaning that the returns and economic benefits from this measure are several times higher than its cost (187, 188). Increasing taxes increases government revenues and can help expand health sector funding Tax increases not only reduce tobacco use and improve health, they also generate more government revenues (121). This additional funding can be used for tobacco control programmes as well as other important health and social initiatives, which have now been successfully demonstrated in some countries (189, 190). using tax revenues in this manner will further increase public support for higher taxes. Taxes should be raised significantly and periodically to reduce the affordability of tobacco products Tobacco products have become increasingly affordable in many countries where income and purchasing power are growing rapidly (191). Despite some of these countries raising tobacco tax rates, these have not been enough to offset inflation and income growth, causing an article 6 of the WHO Framework Convention on Tobacco Control states: “… [P]rice and tax measures are an effective and important means of reducing tobacco consumption … [Parties should adopt] … measures which may include: … tax policies and … price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (1). 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable raISE TaXES ON TOBaCCO – HIGHEST aCHIEvING COuNTrIES, 2018 TOTaL TaX ON CIGarETTES Countries, territories and areas with the highest level of achievement: *andorra, argentina, *australia, austria, Belgium, Bosnia and Herzegovina, *Brazil, Bulgaria, Chile, *Colombia, Croatia, Czechia, *Egypt, Estonia, Finland, France, Greece, Ireland, Israel, Italy, Jordan, Latvia, madagascar, malta, *mauritius, *montenegro, *New Zealand, Niue, *North macedonia, occupied Palestinian territory, including east Jerusalem, Poland, Serbia, Slovakia, Slovenia, Spain, *Thailand, Turkey, and united Kingdom. * Country newly at the highest level since 31 December 2016. Increasing taxes is a highly cost-effective measure to decrease tobacco use many studies have established that raising taxes to increase the price of tobacco products is the single most effective tobacco control measure (23, 121, 183). On average, a 10% price increase will reduce consumption by 5% in low- and middle-income countries (up to 8% in some instances), and by about 4% in high- income countries (121). approximately half of this reduction is due to tobacco users quitting, and half due to existing users smoking less (184). To put these figures into perspective, a recent study estimated that a 50% price increase in 13 selected countries would cause 67 million people to quit (185). erosion of the tax’s value and effectiveness in reducing consumption (192). Nominal tax increases that fail to make tobacco products less affordable are unlikely to reduce consumption and encourage cessation. Governments need to monitor tobacco tax rates and prices relative to real income and significantly raise tax rates at regular intervals as required to ensure that tobacco products do not become more affordable. Tobacco tax policies work better when tax administration is improved Strengthening tax and customs administration as well as improving enforcement capacity amplifies the impacts of raising tobacco taxes (193). Experiences from numerous countries show that illicit trade of tobacco products can be successfully addressed even when taxes and prices are increased, hence the threat of tax evasion should not be used as a reason to forgo tax increases. With the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products entering into force, governments now have more tools at their disposal to control the supply chain and ensure that the right amount of taxes are being paid. On the other hand, tax administration can become easier with the right tax policy. among the different types of tax levied on tobacco products, excise taxes are the most effective at raising prices and triggering significant health impacts (194). Simpler tax structures are likewise easier to administer – complex structures and tiered excise taxes should be avoided to diminish scenarios that can undermine the health and revenue impact of tobacco taxes (193). The world’s population covered by high tobacco taxes doubled between 2016 and 2018 raising the price of tobacco through tobacco taxes – the most effective and efficient way to reduce tobacco use – is the least-achieved mPOWEr measure, with only 14% of the world’s population living in the 38 countries with sufficiently high taxes in 2018. most of the countries that have already adopted high taxes are high-income countries. There is still only a very small number of low- and middle-income countries (15 countries, or 11%) that have adopted high taxes on tobacco. Low-incomeMiddle-incomeHigh-income Data not reported <25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 23 24 5 3 3 Note: Bhutan and Brunei Darussalam are excluded from R because sale of cigarettes is banned. 0 1,750 3,500875 Kilometers Raise taxes o tobacco – Best pra tice countri s, 2018 Best practice countries Sale of cigarettes is banned Other countries Not applicable 108 109WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Since 2016, 10 countries have raised taxes to a level at or above 75% of the price of the most sold brand of cigarettes. The population living in these 10 countries, 462 million people, are now protected by higher taxes. Seven of the countries were middle-income countries: Brazil, Colombia, Egypt, mauritius, montenegro, North macedonia and Thailand. The other three were high-income countries: andorra, australia, and New Zealand. The most significant tax share increase in the 10 countries was made by Colombia, whose 2016 rate of 49.5% was raised to 78.4% by 2018. No low-income countries have raised taxes to 75% or above since 2016. Indeed, only one low-income country (Liberia) increased taxes enough since 2016 to move one category closer to best practice level. and since 2016, three countries (Cyprus, Lithuania and ukraine) dropped out of the best practice group as they were unable to keep their tax share at or above the 75% level. In 2018 the global population protected by high taxes crossed the 1 billion mark Since 2008, progress in raising taxes has been remarkably slow. The population protected by high tobacco taxes remained at around the half-billion mark for 8 years, and only in the past 2 years has the global population protected exceeded 1 billion. However, while in 2008 only one country in 9 imposed taxes comprising 75% or more of the retail price, in 2018 this number has almost doubled: close to one country in five is now protected. There are nine high-income countries that have raised taxes sufficiently to reach the highest level of implementation since 2008, while three high-income countries (Germany, Portugal, and Seychelles) have dropped out of that group. Nine middle- income countries have reached the highest level of taxation since 2008, and three middle-income countries (Cuba, Kenya, and Tunisia) dropped into a lower group. One low-income country began taxing at or above 75% in 2010 (madagascar) and currently remains the only low- income country at the highest level of implementation. In 2008, 82% of the half-million people protected by high tobacco taxes were people living in high-income countries. Today, middle-income countries now contribute more than half of the population (54%) protected by this measure. Only 3% of protected people live in low-income countries. PrOGrESS IN TOTaL TaX ON CIGarETTES ≥75% OF rETaIL PrICE (2008–2018) More countries are adopting recommended excise tax structures on tobacco more countries are now adopting excise tax structures on cigarettes, as recommended in previous editions of the WHO report on the global tobacco epidemic. among the 181 countries tracked over seven reports, the number of countries imposing a specific excise tax structure increased from 57 to 62 between 2008 and 2018, and the number of countries imposing a mixed excise tax structure that relies more on specific excise increased from 22 to 37 during the same period. The number of countries relying on ad valorem excise decreased from 55 in 2008 to 41 in 2018. as of 2018, only 15 countries do not levy an excise tax on tobacco products. This is an important reduction from 2008 when 23 countries had no excise on tobacco products. Notably, 11 of the 15 countries without a tobacco excise tax are low- and middle-income countries. In 2018 half a billion people lived in countries with a tax level within 5 percentage points of the highest level of implementation One in three countries (62) levies taxes that fall short of the 75% threshold but that are at or above 50% of the retail price. Twenty of these countries (with a combined population of half a billion people) have taxes comprising 70% or more of the price, so are within 5 percentage points of best practice. an additional 12 countries (with a combined population of 352 million) are within 10 percentage points of best practice. If all 62 countries in this category increased taxes to 75%, an additional 4.7 billion people would be protected, meaning a total of 5.7 billion people – an incredible 75% of the world’s population – would be protected by high taxes. as of today, over a quarter of the 505 million people who live in one of the world’s 100 largest cities (141 million people in 29 cities) are covered sufficiently by high taxes on cigarette products. For each of the 29 protected cities, the tax rates are implemented at the national level. No city has yet independently (of national government) introduced taxes on tobacco products that have resulted in raising the share of total taxes to 75% or more of the retail price of cigarettes. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 High-income countries Middle-income countries Low-income countries Global Pr ic e an d ta xa ti on p er p ac k (P PP d ol la rs ) Price: PPP $ 4.99 Price: PPP $ 7.80 Price: PPP $ 3.09 Price minus taxes Other taxes Excise tax per pack Price: PPP $ 5.53 Total taxes = PPP $ 5.30 (67.9% of pack price) Total taxes = PPP $ 2.91 (58.3% of pack price) Total taxes = PPP $ 3.36 (60.8% of pack price) Total taxes = PPP $ 1.18 (38.1% of pack price) Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2017. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 53 high-income, 97 middle-income and 28 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors. Numbers may not add exactly due to rounding. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 WEIGHTED avEraGE rETaIL PrICE aND TaXaTION (EXCISE aND TOTaL) OF mOST SOLD BraND OF CIGarETTES, 2018 110 111WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 CHaNGE IN aFFOrDaBILITy OF CIGarETTES, 2008–2018 Note: Change in affordabilty computed as the least squares rate of change in the per capita GDP required to purchase 2000 cigarettes of the most sold brand in local currency in any given year. Please refer to Technical Note III for details of computation. Cigarette prices and taxes continue to be higher in high-income countries, even after adjusting for purchasing power parity Price and tax levels continue to be highest in high-income countries, even when adjusting for differences in purchasing power. Cigarette pack prices, total taxes and the tobacco excise component as a share of pack prices are all lower in low- and middle-income countries, with average total tax as a proportion of price varying between 38% and 58%. This proportion reaches almost 68% in high- income countries, even though the non-tax portion of cigarette prices is fairly similar throughout the world. There is a strong case for all countries, particularly low- and middle-income countries, to increase their excise taxes further, which will have the effect of making cigarettes less affordable. Tobacco use is not effectively discouraged if products become more affordable over time. When price increases do not keep pace with increases in per capita income, tobacco products become more affordable (117, 189). Seeing trends in the affordability of cigarettes over a reference period helps policy-makers understand how cigarette prices have changed relative to the population’s ability to purchase them, and can guide recommended changes in tax policy to influence price levels and effectively reduce consumption. affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. The average change over the period 2008–2018 was then calculated. using this measure, cigarettes became less affordable in 83 countries and did not significantly change in 63 countries, while they became more affordable in 30 countries. Of those 30 countries, 28 were low- and middle-income countries. Low-incomeMiddle-incomeHigh-income Could not be calculated due to insufficent data Cigarettes became more affordable Affordability did not change Cigarettes became less affordable 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ox es ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% In 2015, Colombia’s ministers of Health and Finance recommended a 200% increase in cigarette taxes during the period 2016 to 2017, followed by a 150% increase by 2020, as part of the country’s ongoing effort to reform tax laws. The recommendation aimed to raise the country’s historically very low level of tobacco taxation and revenue to be more in line with WHO recommendations and other countries in the region. The success of the tax hike that was ultimately approved relied on a multisectoral team of experts and health officials from national and international civil society working together to combat industry interference by using solid data and translating it into politically viable policy change. To counteract the argument on the part of the tobacco industry that tax increases would create an unmanageable surge in illicit trade, civil society groups implemented the first public study of the size of the illicit cigarette trade in Colombia and found it represented only a fraction (3.5% of all sales) in the five Colombian cities studied. In December 2016, the Colombian Congress approved a 100% excise tax increase on cigarettes and manufactured tobacco, an additional 50% increase in January 2018 and annual adjustments beginning in January 2019 – equivalent to the annual change in the consumer price index plus 4% (195). This means that the specific tax on cigarettes doubled from 700 Colombian pesos (COP$) per 20-cigarette pack to COP$ 1400 in January 2017 and was subsequently increased to COP$ 2100 in January 2018. as of 2018, the tax share for the most sold brand of cigarettes in Colombia stands at 78.4%, with excise taxes comprising 62.5% (52.5% specific and 10% ad valorem). This places Colombia at the highest level of achievement under the raise taxes on tobacco mPOWEr measure. In terms of impact, in 2017 excise revenues increased by 54% while cigarettes sales declined by 23% in comparison with 2016. Colombia triples cigarette taxes in 2 years rEaL PrICE aND TOTaL TaX SHarE EvOLuTION FOr a PaCK OF mOST SOLD BraND OF CIGarETTES, COLOmBIa 2008–2018 2008 2010 2012 Total tax share of most sold band 2014 2016 2018 1769 1837 2197 2407 2521 3864 Re al p ric e pe r p ac k of 2 0, C O P $ (2 00 8 ba se ) To ta l t ax s ha re , % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Real price per pack of most sold brand, 2008 COP$ Source: (195) 112 113WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2016, countries in the Gulf Cooperation Council (GCC) agreed to introduce an excise tax on products harmful to humans and the environment, including tobacco. Before this agreement, GCC member States (Bahrain, Kuwait, Oman, Qatar, Saudi arabia and the united arab Emirates) had historically relied solely on import duties to tax tobacco, which collectively stood at around 20% of retail price. The new excise tax is an effort both to diversify sources of income and to recognize the danger of tobacco products. Saudi arabia was the first GCC country to implement the excise tax on manufactured tobacco products in June 2017, followed by the united arab Emirates in October 2017 and by Bahrain in December 2017. Qatar joined them in January 2019, and Oman’s excise tax increase is due in June 2019. The new excise tax is harmonized in the GCC at 100% of the retail price excluding taxes, and is already making a noticeable impact on the price of tobacco products. It is expected that the tax and subsequent price increases in these countries will lead to reductions in tobacco consumption and its consequent burden of disease. Gulf Cooperation Council introduces excise tax on harmful products rETaIL PrICE OF mOST SOLD BraND OF CIGarETTES, PPP1 TOTaL TaX aS % OF PrICE OF mOST SOLD BraND OF CIGarETTES Qatar, 5.21 Kuwait, 5.90 Oman, 7.59 UAE, 9.23 Bahrain, 10.15 Saudi Arabia, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 PP P pe r pa ck o f 2 0 ci ga re tt es 1 Purchasing Power Parity or international $ Note: The data in this graph capture changes as of July 2018 and only account for the tax increases in Bahrain, Saudi arabia and united arab Emirates. Bahrain Saudi Arabia United Arab Emirates 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% To ta l t ax Since 2008, the number of countries imposing high taxes has almost doubled: close to one country in five is now protected. 114 115WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 National tobacco control programmes: vital for ending the tobacco epidemic integrated into countries’ broad health and development agendas (196). In large countries or those with federal political systems where governing powers are divided between a central national authority and constituent regional or local political units, decentralizing NTCP authority to subnational level can allow more flexibility in policy development and programme implementation, and potentially enable those policies and programmes to reach a wider population (197). as many tobacco control interventions are carried out at regional and community levels (even when planning occurs nationally), public health and government leaders at the appropriate subnational levels need adequate resources to build implementation capacity that can be sustained over time (94). NTCPs should also ensure that population subgroups with disproportionately high rates of tobacco use are reached by policies and programmes tailored to their needs (197). Tobacco control requires active civil society participation NTCPs require support not only from government partners but also from civil society; this specifically excludes the tobacco industry and its allies, which cannot be legitimate stakeholders in tobacco control efforts (94). Continued involvement by appropriate nongovernmental organizations and other civil society groups is essential to maintaining continued progress on national as well as global tobacco control efforts (197). Two thirds of world’s population covered by a national agency for tobacco control One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Fortunately, because many of these countries are populous, two thirds of the world’s population is protected by such an agency. an additional 117 countries (with one third of the world’s population) are working on tobacco control objectives with fewer staff (84 countries), or with an unknown number of staff (33 countries). Only 17 countries (with 145 million people) do not have a national agency for tobacco control, 14 of which are low- and middle-income countries. In the past 2 years, only three countries enhanced their national tobacco control programmes sufficiently to reach the highest level of adoption (Botswana, Iraq and Qatar), adding 44 million people to the population covered. at the same time, one country dropped below best-practice level: Suriname reduced the number of staff dedicated full-time to tobacco control. Since 2008, an additional 15 countries, with 499 million people, have established a well-staffed national team working full- time on tobacco control. It is worth noting that this measure may underestimate the true extent of NTCPs in countries because information on tobacco control programme staffing at the national level is incomplete, with no formal mechanism for collecting this information from countries. The WHO Framework Convention on Tobacco Control strongly suggests that countries to set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (1). Low-incomeMiddle-incomeHigh-income Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with fewer than 5 staff or staff not reported Existence of national agency with responsibility for tobacco control objectives and at least 5 staff members 23 58 33 58 11 Pr op or ti on o f c ou nt ri es (n um be r of c ou nt ri es in si de b ar s) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 NaTIONaL TOBaCCO CONTrOL PrOGrammES PrOGrESS IN NaTIONaL TOBaCCO CONTrOL PrOGrammES (2008–2018) Decentralizing nTCP authority is important adequately financed, clearly focused NTCPs or coordination mechanisms are critical for developing and maintaining the sustainable policies that can reverse the tobacco epidemic (1). ministries of health, or equivalent government agencies, should take the lead on strategic tobacco control planning and policy setting, with other ministries or agencies reporting to this centralized authority (175). Tobacco control programmes should also be 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Population (billions) Countries Total population: 7.6 billion Total number of countries: 195 N um be r of c ou nt ri es 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 Po pu la tio n pr ot ec te d (b ill io ns ) 116 117WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In 2003 Ireland became the first country in the world to implement smoke-free environments. Tobacco consumption, however, continues to have a huge impact on Ireland, with at least 5500 people dying from tobacco-related diseases each year. although the country has a strong tobacco control track record and use has gradually decreased over the past few decades, in 2013 Ireland decided to bring tobacco control to the “endgame”, or final stages of achieving a tobacco-free Ireland. In order to achieve this, the plan makes 60 recommendations to significantly reduce smoking to less than 5% of the adult population by 2025. It was estimated that more than 55 000 current smokers would have to quit each year for the next 10 years to reach this ambitious target. The Tobacco Free Ireland policy was developed by Ireland’s Department of Health and its Health Service Executive in 2013. This government strategy (2013–2025) works to coordinate and lead tobacco control activity across the health service and has several cross-governmental actions based on mPOWEr measures, with the goal of denormalizing tobacco use in Ireland, especially for the next generation. Ireland’s 2017 status report on the progress of the Tobacco Free Ireland policy shows great progress, including legislation requiring standardized packaging of tobacco products and the development of the new QuIT campaign, which aims to enhance support for people who wish to quit smoking. In 2018 a Health Service Executive national implementation plan (2018–2021) was published, establishing the strategic direction and priority actions required to achieve the goals set out in the plan. Over the next 4 years the objectives of the Tobacco Free Ireland policy include prioritizing the protection of children in all initiatives and encouraging the denormalization of tobacco use for future generations; supporting people to quit and treating tobacco dependence as a health care issue; and monitoring, building, and maintaining compliance through tobacco legislation. The Tobacco Free Ireland Programme One in four countries globally has a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people. Campaign for the Tobacco Free Ireland Programme. madagascar has demonstrated huge commitment and progress towards tobacco control, and to date has adopted four of the mPOWEr measures at the highest level of achievement. In 2007, the Consultative Committee of anti-Tobacco Control (CCoLaT) was created to support coordination of WHO FCTC implementation activities across all sectors. This multisectoral committee meets every three months, comprising members from a wide range of ministries and civil society organizations working to combat tobacco use. The committee plays an intermediary role between the ministry of Health and their corresponding entities and provides an opportunity for effective collaboration. For example, civil society organizations and certain ministerial departments (Sport, National Education, Population, Health) have worked together to develop and deliver public awareness-raising activities. The CCoLaT also plays a monitoring role and sounds the alarm in case of non- compliance with regulations and industry interference. In addition, and with the support of the ministry of the Interior, the country is gradually setting up multi-sector committees in different regions of the country. Through these coordinating mechanisms, madagascar continues to demonstrate its dedication to the fight against tobacco epidemic to save lives and improve the well-being of the population. Multisectoral collaboration boosts tobacco control, Madagascar Awareness raising during World No Tobacco Day 2018, Madagascar. 118 119WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Conclusion There has been substantial progress made globally since the 2003 adoption of the WHO FCTC. The successful scaling up of mPOWEr measures over the past 10 years to the best-practice level, adopted by countries of all sizes and income levels, is evidence of the successful implementation of the WHO FCTC demand reduction measures. as countries continue to work towards creating and implementing effective tobacco control strategies they can find encouragement in the examples set by other countries that have successfully adopted measures at best- practice levels. In the years since mPOWEr was launched, the challenges faced have been great. There have been, and will continue to be, setbacks, unexpected barriers, interference from the tobacco industry and difficult political obstacles to overcome. Despite these challenges, there are now 5 billion people who are protected by at least one best-practice tobacco control measure – 3.9 billion more than were covered in 2007. On the other hand, 2.6 billion people remain unprotected by evidence- based tobacco control best-practices, leaving them at risk from the health and economic harms caused by tobacco use. millions of lives have been saved since the introduction of mPOWEr, and it has only been through the coordinated focus of a global community that tobacco control efforts have been so successful. unfortunately, however, the tobacco epidemic is far from over. although tobacco use has declined in most countries and regions, population growth means the total number of people using tobacco has remained stubbornly high. Tobacco control programmes are not always quick and easy to implement, and all countries can benefit from strengthened tobacco control policy development and enforcement. Since the last report, only one country – Brazil – has joined Turkey in putting all mPOWEr measures in place at their most comprehensive level, and there are only a handful of other countries that have more than two measures in place at best- practice levels. Even in countries where best-practice measures exist, much can be done to strengthen compliance and ensure full impact. The focus of this report, Offer help to quit tobacco use, is the “O” of mPOWEr. Only 23 countries provide cessation services at best-practice level, even though in many countries, many tobacco users report wanting to quit. Nevertheless, progress is being made – 2 billion more people have been covered by comprehensive tobacco cessation services since 2007, and there are 67 countries that are only one step away from providing comprehensive tobacco cessation services. middle-income countries have made most obvious progress in providing tobacco cessation support in primary care settings and operating national toll-free quit lines since 2007. The evidence shows tobacco users’ chances of quitting successfully improve dramatically if they use effective cessation interventions. This report provides guidance for countries on effective cessation services and how those services can be provided to best meet the needs of tobacco users who want to quit, in line with article 14 of the WHO FCTC. Countries should, at the minimum, provide brief advice on quitting to all tobacco users whenever they consult a primary health care provider for any reason. Countries should also provide a national toll-free quit line and mCessation services to reach a larger population. Finally, providing cost-covered nicotine replacement therapy will help increase quit rates. Combining two or more of these approaches further increases tobacco cessation success. Even low-income countries with limited resources can start to integrate brief advice into existing primary health care systems as one of the first actions to develop their tobacco cessation support. Brief advice in primary care should be included in universal health coverage to potentially benefit 80% of all tobacco users a year. Currently, only 18 countries are providing fully cost-covered tobacco cessation support in most of their primary care facilities and others should follow suit. Every country has an obligation to protect the health of its people, and all Parties to the WHO FCTC have made a specific commitment to implement strong tobacco control policies, including effective cessation services, as an important means of fulfilling their obligation to protect the health of their people. There has been incredible progress in the 11 years since mPOWEr monitoring began, including millions of lives saved, but it is only the beginning. It is important that we all recommit to ensuring all the people of the world are protected fully from the great harms of the tobacco epidemic. 120 121WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 References 13. WHO Global report on trends in prevalence of tobacco smoking 2000-2025, Second edi- tion. 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Geneva: World Health Organization; 2010 (http://www.who.int/tobacco/publica- tions/tax_administration/en, accessed 26 June 2019). 194. Petit P, Nagy J. Fiscal policy: how to design and enforce tobacco excises? Washington, DC; International monetary Fund; 2016 (https://www.imf.org/external/pubs/ft/how- tonotes/2016/howtonote1603.pdf, accessed 26 June 2019). 195. report on tobacco control in the region of the americas. Washington, DC: Pan american Health Organization; 2018 (http://iris.paho.org/ xmlui/handle/123456789/49237, accessed 26 June 2019). 196. reddy KS, yadav a, arora m, Nazar GP. Integrating tobacco control into health and development agendas. Tobacco Control. 2012;21:281–6. 197. David a, Esson K, Perucic a-m, Fitzpatrick C. Tobacco use: equity and social deter- minants. Geneva: World Health Organiza- tion; 2010. (http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 126 127WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAl NOTES TECHNICaL NOTE I Evaluation of existing policies and compliance TECHNICaL NOTE II Tobacco use prevalence in WHO Member States TECHNICaL NOTE III Tobacco taxes in WHO Member States APPENDICES aPPENDIX I Regional summary of MPOWER measures aPPENDIX II Tobacco dependence treatment aPPENDIX III Year of highest level of achievement in selected tobacco control measures aPPENDIX Iv Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world aPPENDIX v Status of the WHO Framework Convention on Tobacco Control aPPENDIX vI Global tobacco control policy data aPPENDIX vII Country profiles aPPENDIX vIII Tobacco tax revenues aPPENDIX IX Tobacco taxes, prices and affordability aPPENDIX X Age-standardized prevalence estimates for tobacco use, 2017 aPPENDIX XI Country-provided prevalence data aPPENDIX XII Maps on global tobacco control policy data Appendices VI to XII are available online at http://www.who.int/tobacco/ global_report/en/ 128 129WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE I Evaluation of existing policies and compliance This report provides summary indicators of country achievements for each of the mPOWEr measures, and the methodology used to calculate each indicator is described in this Technical Note. To ensure consistency and comparability, the data collection and analysis methodology used in this report are largely based on previous editions of the report. Some details of the methodology employed in earlier reports, however, have been revised and strengthened for the present report. Where revisions have been made, data from previous reports have been re-analysed so that results are comparable across years. Data sources Data were collected using the following sources: • For all areas: official reports from WHO FCTC Parties to the Conference of the Parties (COP) and their accompanying documentation.1 • For m (monitoring): tobacco prevalence surveys not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. Technical Note II provides further details. • For P (protect people from tobacco smoke), W (warn about the dangers of tobacco) and E (enforce bans on tobacco advertising, promotion and sponsorship): original tobacco control legislation (including regulations) adopted in all member States that relate to smoke-free environments, packaging and labelling measures and tobacco advertising, promotion and sponsorship. In cases where a law had been adopted by 31 December 2018 but had not yet entered into force, the respective law was assessed and data were reported with an asterisk denoting “provision adopted but not implemented by 31 December 2018”. • For W (mass media): data on anti-tobacco mass media campaigns were obtained from member States. In order to avoid unnecessary data collection, WHO conducted a screening for anti-tobacco mass media campaigns in all WHO Country Offices. In countries where potentially eligible mass media campaigns were identified, focal points in each country were contacted for further information on these campaigns, and data on eligible campaigns were gathered and systematically recorded. • For O (offer help to quit tobacco use): data not reported under the COP reporting mechanism were collected mainly through WHO regional and WHO Country Offices. • For r (raise taxes on tobacco): the prices of the most sold brand of cigarettes, the cheapest brand and a premium brand were collected through regional data collectors. Information on the taxation of cigarettes (and when possible, most commonly used other smoked and smokeless tobacco products) and revenues from tobacco taxation was collected from ministries of finance. Technical Note III provides the detailed methodology used. Based on these sources of information, WHO assessed each indicator as of 31 December 2018. Exceptions to this cut-off date were tobacco product prices and taxes (cut-off date 31 July 2018) and anti-tobacco mass media campaigns (cut-off date 30 June 2018). Data validation For each country, every data point for which legislation was the source was assessed by two expert staff from two different WHO offices, generally one from WHO headquarters and the other from the respective WHO regional Office. any inconsistencies were reviewed by the two WHO expert staff involved and a third expert staff member not yet involved in the appraisal of the legislation. Disagreements in the interpretation of the legislation were resolved by: (i) checking the original texts of the legislation; (ii) trying to obtain consensus from the two expert staff involved in the data collection; (iii) trying to obtain clarification from judges or lawyers in the concerned country; and (iv) the decision of the third expert in cases where differences remained. Data were also checked for completeness and logical consistency across variables. Data sign-off Final, validated data for each country were sent to the respective government for review and sign-off. To facilitate review by governments, a summary sheet was generated for each country and was sent for review prior to the close of the report database. In cases where national authorities requested data changes, the requests were assessed by WHO expert staff according to both the legislation/materials and the clarification shared by the national authorities, and data were updated or left unchanged. In cases where national authorities explicitly did not agree with the data assessment, this is specifically noted in the appendix tables. Further details about the data processing procedure are available from WHO. Data analysis It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. Data from laws not in effect by 31 December 2018 have a footnote stating this. The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The report provides analysis of progress made between 2016 and 2018, and between 2007 and 2018 using the latest assessment of the status of measures in each year so that the results are comparable across years. For r, the earliest comparable data are 2008 and for mass media, data are available only from 2010. To calculate the change in the percentage of the population covered by each policy or measure over time, population estimates for the year 20182 were used. using a static year eliminates the effect of population growth when measuring change over time. Indicators from previous years have been recalculated, according to legislation/ materials received after the assessment period of the respective report or according to changes in the indicator methodology. all income groups used for this report derive from the World Bank income-group classification published on 1 July 2018 by the World Bank.3 upper-middle and lower-middle income groups are combined into one group for this report. When country or population totals for mPOWEr measures are referred to collectively in the analysis section of this report, only the implementation of tobacco control policies (smoke-free legislation, cessation services, warning labels, advertising, promotion and sponsorship bans, and tobacco taxes) is included in these totals. monitoring of tobacco use and anti-tobacco mass media campaigns are reported separately. Correction to previously published data The 2016 data published in the last report were reviewed, and about 3% of data points were corrected. The full set of mPOWEr data revised for all years back to 2007 is available in an Excel file on the report website. Monitoring of tobacco use and prevention policies The strength of a national tobacco surveillance system is assessed by the frequency and periodicity of nationally representative youth and adult surveys in countries. Countries are grouped in the top monitoring category when all criteria listed below are met for both youth and adult surveys: • whether a survey was carried out recently; • whether the survey was representative of the country’s population; • whether a similar survey was repeated within 5 years (periodic); and • whether the youth and adult populations were surveyed through school-based and household population-based surveys respectively. Surveys were considered recent if conducted in the past 5 years. For this report, this means 2013 or later. Surveys were considered representative only if a scientific random sampling method was used to ensure nationally representative results. (although they provide useful information, subnational surveys or national surveys of specific population groups provide insufficient information to enable tobacco control action for the total population.) Surveys were considered periodic if the same survey or a survey using the same or similar questions was repeated at least once every 5 years. The following definitions were applied for youth and adult surveys: youth surveys: school-based surveys of students aged 13–15 years. The questions asked in the surveys should provide indicators that are consistent with those specified in the Global youth Tobacco Survey questionnaires and manuals. Adult surveys: population-based surveys that can provide indicators for adults aged 15 years and over, consistent with those specified in the Global adult Tobacco Survey questionnaires and manuals. The groupings for the monitoring indicator are listed below. No known data or no recent* data or data that are not both recent* and representative** recent* and representative** data for either adults or youth recent* and representative** data for both adults and youth recent*, representative** and periodic*** data for both adults and youth * Data from 2013 or later. ** Survey sample representative of the national population. *** Collected at least every 5 years. Smoke-free legislation There is a wide range of places and institutions that can be made smoke-free by law. Smoke- free legislation can be in place at the national or subnational level. The report includes data based on national legislation, and legislation in subnational jurisdictions where available and where national laws are incomplete. The assessment of subnational smoke-free legislation includes first-level administrative subdivisions of a country, as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of the subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of smoke-free legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Legislation was assessed to determine whether smoke-free laws provided for a complete4 indoor smoke-free environment at all times, in all the facilities of each of the following eight places: • health care facilities; • educational facilities other than universities; • universities; • governmental facilities; • indoor offices and workplaces not considered in any other category; • restaurants or facilities that serve mostly food; • cafés, pubs and bars or facilities that serve mostly beverages; • public transport. Groupings for the smoke-free legislation indicator are based on the number of places where indoor smoking is completely prohibited. Countries with no complete smoking ban at national level but where at least 90% of the population is covered by complete subnational smoke-free laws are grouped in the top category. The groupings for the smoke-free legislation indicator are listed below. Not reported/not categorized Complete absence of bans, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke- free (or at least 90% of the population covered by complete subnational smoke- free legislation) In addition to the data used for the above groupings of the smoke-free legislation indicator, other related data such as information on fines and enforcement were collected and are reported in appendix vI. 130 131WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 In a few countries, in order to significantly expand the creation of smoke-free places, including restaurants and bars, it was politically necessary to include exceptions to the law that allowed for the provision of designated smoking rooms (DSrs) with requirements so technically complex and strict that, for practical purposes, few or no establishments are expected to implement them. In order to meet the criteria for “very strict technical requirements”, the legislation has to include at least three out of the six following characteristics (and must include at least criteria 5 or 6). The designated smoking room must: 1. be a closed indoor environment; 2. be furnished with automatic doors, generally kept closed; 3. be non-transit premises for non-smokers; 4. be furnished with appropriate forced- ventilation mechanical devices; 5. have appropriate installations and functional openings installed, and air must be expelled from the premises; 6. be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals. The few countries whose laws provide for DSrs with very strict technical requirements for five or more of the assessed public places have not been categorized in the analyses for this section because their smoke-free legislation substantially departs from the recommendations of WHO FCTC article 8 guidelines, and it has been difficult to obtain evidence indicating that the law resulted in the intended very low number of DSrs in these countries. The countries whose laws provide for DSrs with very strict technical requirements for fewer than five of the assessed public places have been grouped according to the number of completely smoke-free public places. Tobacco dependence treatment The indicator of achievement in treatment for tobacco dependence is based on whether the country has available: • nicotine replacement therapy (NrT); • smoking cessation support; • reimbursement for any of the above; and • a national toll-free quit line. Despite the low cost of quit lines, few low- or middle-income countries have implemented such programmes. Thus, national toll-free quit lines are included as a qualification only for the highest category. reimbursement for tobacco dependence treatment is considered only for the top two categories to take restricted national budgets of many lower-income countries into consideration. The top three categories reflect varying levels of government commitment to the provision of nicotine replacement therapy and cessation support. The groupings for the tobacco dependence treatment indicator are listed below. Data not reported None NrT* and/or some cessation services** (neither cost-covered) NrT* and/or some cessation services** (at least one of which is cost-covered) National quit line, and both NrT* and some cessation services** (cost-covered) * Nicotine replacement therapy. ** Smoking cessation support available in any of the following places: health clinics or other primary care facilities, hospitals, office of a health professional, the community or other settings. In addition to data used for the grouping of the tobacco dependence treatment indicator, other related data such as information on countries’ essential medicines lists, etc. were collected and are reported in appendix vI. For this edition of the WHO report on the global tobacco epidemic, countries were asked additional questions about their cessation services. The questions included focused on policies and guidelines, structural capacity and the integration of cessation into other tobacco control approaches. Data collected are presented in appendix II. Policies and guidelines National tobacco strategy: to be eligible a country’s national strategy had to be operational Clinical Guidelines: countries were asked about the presence of national clinical guidelines for tobacco cessation, as well as the inclusion of tobacco cessation in clinical or treatment guidelines for: • Tuberculosis • Cardiovascular diseases • Hypertension • respiratory diseases • Diabetes • Cancer • Psychiatric disorders • Oral diseases • reproductive health Survey responses were reviewed and verified using supporting documentation that was either (a) attached by survey respondents, or (b) where applicable, found in the WHO Noncommunicable Disease Document repository. For the sake of cross-country comparability, only national-level guidelines were deemed to be eligible. To be considered eligible, clinical guidelines were required to meet the following two criteria: • Be statements or recommendations regarding clinical practice that would assist clinicians and patients in optimizing patient care. • Explicitly recommend tobacco cessation, or require clinicians to ask and record tobacco use status during the patient interview (e.g., using a standardized form or risk calculator). PEN (package of essential noncommunicable disease interventions for primary health care in low-resource settings) protocols, regional (multi- country) guidelines, and international guidelines were accepted in place of country-specific guidelines in cases where national adoption could be demonstrated. Integrated or primary care guidelines including practitioner handbooks were also considered eligible. Structural capacity Countries were asked whether they routinely recorded tobacco use in medical records (supporting documentation required) and whether cessation was part of a degree curriculum for primary care providers. Integrating cessation into other tobacco control approaches Countries were asked if information about a toll-free quit line had been included on cigarette packages or in mass media campaigns over the last 12 months. Supporting documentation was required and verified. Nicotine replacement therapy cost analysis NrT price data was sourced from Euromonitor which included 56 countries – 37 high-income and 19 middle-income, as grouped by World Bank country income classification. Total costs were calculated assuming a simplified NrT regimen lasting 8 weeks. Based on expert recommendations, the commodity requirement for this period was set at either 56 patches (once daily), or 532 pieces of gum (12 pieces daily for 4 weeks, 8 pieces daily the next 2 weeks, then 6 pieces daily the last 2 weeks). The pack size(s) available in each country was also considered when the least expensive option was calculated. It was also assumed that those more heavily dependent on nicotine will consume the same amount of gum/patches as those who are less dependent, although using an appropriate NrT option with higher nicotine concentrations. Since prices for different nicotine concentrations of the same brand did not vary significantly (<5%), the simulated costs were uniform regardless of the level of dependence. To have comparability across countries, the total price for each NrT option was adjusted for purchasing power and converted to International Dollars using the ImF 2018 Implied PPP Conversion rate. This was compared to the cost of smoking the cheapest pack of cigarettes daily during the same period, using the price data submitted for this report. Lastly, simple averages were calculated for each grouping, either by country income or cost-coverage. Warning labels on tobacco packaging The section of the report that assesses each country’s legislation on health warnings includes the following information about cigarette package warnings: • whether specific health warnings are mandated; • the mandated size of the warnings, as a percentage of the front and back of the cigarette package; • whether the warnings appear on individual packages as well as on any outside packaging and labelling used in retail sale; • whether the warnings describe specific harmful effects of tobacco use on health; • whether the warnings are large, clear, visible and legible (e.g. specific colours and font styles and sizes are mandated); • whether the warnings rotate; • whether the warnings are written in (all) the principal language(s) of the country; • whether the warnings include pictures or pictograms. The size of the warnings on both the front and back of the cigarette pack were averaged to calculate the percentage of the total pack surface area covered by warnings. This information was combined with the warning characteristics to construct the groupings for the health warnings indicator. The groupings for the health warnings indicator are listed below. Data not reported No warnings or small warnings 1 medium size warnings 2 missing some3 or many 4 appropriate characteristics5 Or large warnings 6 missing many 4 appropriate characteristics5 medium size warnings 2 with all appropriate characteristics5 Or large warnings6 missing some 3 appropriate characteristics 5 Large warnings 6 with all appropriate characteristics5 1 average of front and back of package is less than 30%. 2 average of front and back of package is between 30 and 49%. 3 One to three. 4 Four or more. 5 appropriate characteristics: • specific health warnings mandated; • appearing on individual packages as well as on any outside packaging and labelling used in retail sale; • describing specific harmful effects of tobacco use on health; • are large, clear, visible and legible (e.g. specific colours and font style and sizes are mandated); • rotate; • include pictures or pictograms; • written in (all) the principal language(s) of the country. 6 average of front and back of the package is at least 50%. In addition to the data used for the grouping of the health warnings indicator, other related data such as the appearance of the quit line number, the requirement for plain packaging, etc. were collected and are reported in appendix vI. Plain packaging (also called standardized packaging) is defined by WHO FCTC article 11 guidelines as a measure “to restrict or prohibit the use of logos, colours, brand images or promotional information on packaging other than brand names and product names displayed in a standard colour and font style”. In order for a country to appear in this report as having introduced plain packaging, the following criteria (established by WHO FCTC article 13 guidelines) are requested: • black and white or two other contrasting colours, as prescribed by national authorities; • nothing other than a brand name, a product name and/or manufacturer’s name, contact details and the quantity of product in the packaging, without any logos or other features apart from health warnings, tax stamps and other government-mandated information or markings; • prescribed font style and size; • standardized shape, size and materials: • there should be no advertising or promotion inside or attached to the package or on individual cigarettes or other tobacco products. 132 133WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The first four types of advertising listed are termed “direct” advertising, and the remaining six are termed “indirect” advertising. Complete bans on tobacco advertising, promotion and sponsorship usually start with bans on direct advertising in national media and progress to bans on indirect advertising as well as promotion and sponsorship. The basic distinction for the two lowest groups is whether bans cover national television, radio and print media or not, and the remaining groups were constructed based on how comprehensively the law covers bans of other forms of direct and indirect advertising included in the questionnaire. In cases where the law did not explicitly address cross-border advertising, it was interpreted that advertising at both domestic and international levels was covered by the ban only if advertising was totally banned at national level. The groupings for the bans on advertising, promotion and sponsorship indicator are listed below. Countries where at least 90% of the population were covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship are grouped in the top category. Data not reported Complete absence of ban, or ban that does not cover national television (Tv), radio and print media Ban on national Tv, radio and print media only Ban on national Tv, radio and print media as well as on some (but not all) other forms of direct* and/or indirect** advertising Ban on all forms of direct* and indirect**advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) * Direct advertising bans: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor). ** Indirect advertising bans: • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco goods and services identified with tobacco brand names (brand stretching); • brand names of non-tobacco products used for tobacco products (brand sharing); • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship, (contributions and/or publicity of contributions). In addition to the data used for the grouping of the bans on advertising, promotion and sponsorship indicator, other related data, such as bans on internet sales or on display of tobacco products at points of sale were collected and are reported in appendix vI. Anti-tobacco mass media campaigns Countries undertake communication activities for many reasons, including improving public relations, creating attention for an issue, building support for public policies, and prompting behaviour change. anti-tobacco communication campaigns, which are a core tobacco control intervention, must have specified features in order to be minimally effective: they must be of sufficient duration and must be designed to effectively support tobacco control priorities, including increasing knowledge, changing social norms, promoting cessation, preventing tobacco uptake, and increasing support for good tobacco control policies. With this in mind, and consistent with the definition of “anti-tobacco mass media campaigns” in the last report, only mass media campaigns that were: (i) designed to support tobacco control; (ii) at least 3 weeks in duration and (iii) implemented between 1 July 2016 and 30 June 2018 were considered eligible for analysis. For the sake of logistical feasibility and cross-country comparability, only national-level campaigns were considered eligible. Consistent with the last report and to enable greater accuracy, materials from campaigns had to be submitted and verified based on the eligibility criteria for all countries. Eligible campaigns were assessed according to the following characteristics, which signify the use of a comprehensive communication approach: 1. The campaign was part of a comprehensive tobacco control programme. 2. Before the campaign, research was undertaken or reviewed to gain a thorough understanding of the target audience. 3. Campaign communication materials were pre-tested with the target audience and refined in line with campaign objectives. 4. air time (radio, television) and/or placement (billboards, print advertising, etc.) were obtained by purchasing or securing it using either the organization’s own internal resources or an external media planner or agency (this information indicates whether the campaign adopted a thorough media planning and buying process to effectively and efficiently reach its target audience). 5. The implementing agency worked with journalists to gain publicity or news coverage for the campaign. 6. Process evaluation was undertaken to assess how effectively the campaign had been implemented. 7. an outcome evaluation process was implemented to assess campaign impact. 8. The campaign was aired on television and/ or radio. The groupings for the mass media campaigns indicator are listed below. Data not reported No national campaign conducted between July 2016 and June 2018 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio Bans on advertising, promotion and sponsorship The report includes data on legislation in national as well as subnational jurisdictions. The assessment of subnational legislation on advertising, promotion and sponsorship bans includes first-level administrative subdivisions as listed in ISO3166. Subnational data reported in appendix vI only reflect the content of subnational laws. Provisions covered by national legislation are indicated by an informative note next to the subnational data. In cases where the status of advertising, promotion and sponsorship legislation is not reported for some or all subnational jurisdictions, we assume the existing national law applies. Country-level achievements in banning tobacco advertising, promotion and sponsorship were assessed based on whether the bans covered the following types of advertising: • national television and radio; • local magazines and newspapers; • billboards and outdoor advertising; • point of sale (indoor); • free distribution of tobacco products in the mail or through other means; • promotional discounts; • non-tobacco products identified with tobacco brand names (brand stretching);5 • brand names of non-tobacco products used for tobacco products (brand sharing);6 • appearance of tobacco brands (product placement) or tobacco products in television and/or films; • sponsorship (contributions and/or publicity of contributions). The compliance assessment was obtained for legislation adopted by 1 april 2018. For countries with more recent legislation, compliance data are reported as “not applicable”. Compliance with smoke-free legislation was not assessed in cases where the law provides for DSrs with very strict technical requirements. The compliance assessments are listed in appendix vI. appendix I summarizes this information. Compliance scores are represented separately from the grouping (i.e. compliance is not included in the calculation of the grouping categories). 1. Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/. 2. united Nations Department of Economic and Social affairs, Population Division in World population prospects: the 2017 revision (median fertility projection for the year 2018). For more information please refer to https:// population.un.org/wpp/Download/Standard/Population/. 3. The World Bank: World development indicators published July 1, 2018. For more information please refer to https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4. “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long- term health and social care facilities such as psychiatric units and nursing homes. ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places. 5. When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. 6. When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply. Tobacco taxes Countries are grouped according to the percentage contribution of all tobacco taxes to the retail price of a pack of 20 of the most popular brand of cigarettes. Taxes assessed include excise tax, value added tax (sometimes called “vaT”), import duty (when the cigarettes were imported) and any other taxes levied. In the case of countries where different levels of taxes applied to cigarettes are based on length, quantity produced, or type (e.g. filter vs. non-filter), only the rate that applied to the most popular brand is used in the calculation. Given the lack of information on country and brand-specific profit margins of retailers and wholesalers, their profits were assumed to be zero (unless provided by the national data collector). The groupings for the tobacco tax indicator are listed below. Please refer to Technical Note III for more details. Data not reported < 25% of retail price is tax ≥ 25% and < 50% of retail price is tax ≥ 50% and < 75% of retail price is tax ≥ 75% of retail price is tax Trend in affordability of the most sold brand of cigarettes The affordability of cigarettes was computed as the percentage of per capita GDP required to purchase 2000 cigarettes of the most popular brand in each year of this report from 2008 to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure. The groupings for the affordability indicator are listed at the top of the next column. Please refer to Technical Note III for more details. YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 No trend change in affordability of cigarettes since 2008 … Insufficient data to conduct a trend analysis national tobacco control programmes Classification of countries’ national tobacco control programmes is based on the existence of a national agency with responsibility for tobacco control objectives. Countries with at least five full-time equivalent staff members working at the national agency with responsibility for tobacco control meet the criteria for the highest group. The groupings for the national tobacco control programme indicator are listed below. Data not reported No national agency for tobacco control Existence of national agency with responsibility for tobacco control objectives with no or fewer than five full-time equivalent staff members Existence of national agency with responsibility for tobacco control objectives and at least five full-time equivalent staff members Compliance assessment Compliance with national and comprehensive subnational smoke-free legislation as well as with advertising, promotion and sponsorship bans was assessed by up to five national experts, who scored the compliance in these two areas as “minimal”, “moderate” or “high”. These five experts were selected according to the following criteria: • person in charge of tobacco prevention in the country’s ministry of health, or the most senior government official in charge of tobacco control or tobacco-related conditions; • the head of a prominent nongovernmental organization dedicated to tobacco control; • a health professional (e.g. physician, nurse, pharmacist or dentist) specializing in tobacco- related conditions; • a staff member of a public health university department; • the tobacco control focal point of the WHO Country Office. The experts performed their assessments independently. average scores were calculated by WHO from the five individual assessments by assigning two points for highly enforced policies, one point for moderately enforced policies and no points for minimally enforced policies, with a potential minimum of 0 and maximum of 10 points in total from these five experts. 134 135WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 TECHNICAL NOTE II Tobacco use prevalence in WHO Member states monitoring the prevalence of tobacco use is central to efforts to control the global tobacco epidemic. reliable prevalence data on the magnitude of the tobacco epidemic and its influencing factors provide the information needed to plan, adopt and evaluate the impact of tobacco control interventions. This report contains survey data for both smoking1 and smokeless tobacco use among young people and adults (appendix XI). It also presents WHO-modelled, age-standardized prevalence estimates for tobacco use for people aged 15 years and over (appendix X). This technical note provides information on the method used to generate the WHO prevalence estimates. Sources of information For the analysis, the following sources of information were explored (where official survey reports explaining the sampling, methodology and detailed results were not publicly available, member States were asked to provide them): • information on surveys provided by Parties to the WHO FCTC Secretariat; • information collected through WHO tobacco- focused surveys conducted under the aegis of the Global Tobacco Surveillance System – in particular, the Global adult Tobacco Survey (GaTS); • tobacco information collected through other WHO surveys including WHO STEPwise surveys and World Health Surveys; • other systems-based surveys undertaken by other organizations, including surveys such as the Demographic and Health Surveys (DHS) and the multiple Indicator Cluster Survey (mICS); and • an extensive search through WHO regional offices and WHO country offices to identify country-specific surveys not part of international surveillance systems – such as the National Survey of risk Factors in argentina, or the mauritius Non Communicable Diseases Survey. For the analysis, information from surveys conducted since 1990 was used if it: • was officially recognized by the national health authority; • included randomly selected participants who were representative of the general population; • provided data for one or more of six tobacco use definitions: daily tobacco user, current tobacco user, daily tobacco smoker, current tobacco smoker, daily cigarette smoker or current cigarette smoker; and • presented prevalence values by age and sex. The above indicators provide for the most complete representation of tobacco use across countries and at the same time help minimize attrition of countries from further analysis because of lack of adequate data. although differences exist in the types of tobacco products used in different countries and grown or manufactured in different regions of the world, data on these six indicators are available in most countries, thereby permitting robust statistical analyses.2 The information identified above is stored in the WHO Tobacco Control Global DataBank and, along with the source code used for generating the WHO smoking prevalence estimates, is published alongside this report at http://www. who.int/tobacco/. Analysis and presentation of tobacco use prevalence indicators Estimation method a statistical model based on a Bayesian negative binomial meta-regression was used to model crude adjusted and age-standardized estimates for countries for each indicator (current and daily tobacco use, current and daily tobacco smoking, and current and daily cigarette smoking) separately for men and women. a trend was considered to be statistically significant if the posterior probability of the increase or decrease was greater than 0.75. a full description of the method is available as a peer-reviewed article in the Lancet, volume 385, No. 9972, p966–976 (2015). Once the prevalence rates from national surveys were compiled into a dataset, the model was fit to calculate trend estimates for the six indicators specified above. The model has two main components: (a) adjusting for missing indicators and age groups, and (b) running the regression to generate an estimate of trends over time as well as the credible interval around the estimate. Depending on the completeness of survey data from a particular country, the model at times makes use of data from other countries to fill information gaps. Countries with data gaps “borrow information” from “priors” calculated from their data pooled with data from countries in the same uN subregion3. Differences in age groups covered by each survey Survey results for any one country were sometimes reported for a variety of different age groups. Where data were missing for any age group in the range of 15 years and above, the model uses available data from a country’s other surveys to estimate the age pattern of tobacco use. For ages that the country has never surveyed, the average age pattern seen in countries in the same uN subregion is applied to the country’s data. Differences in the indicators of tobacco use measured Similarly, countries may report different indicators across surveys (e.g. current smoking in one survey and daily smoking in another, or tobacco smoking in one and cigarette smoking in another). Where data were missing for any indicator, the model uses available data from a country’s other surveys to estimate the missing information. For indicators on which the country has never reported, the average relationships seen in countries in the same uN subregion are applied to the country’s data. modelled results The model was run for all countries with surveys that met the inclusion criteria. results for countries with insufficient survey data (e.g. only one survey with a detailed age breakdown for prevalence for either sex) were not reported. The output of the model is a set of trend lines for each country that summarize its prevalence history from 2000 to the most recent survey, and project trends to 2030. Countries with few surveys will have more borrowed information blended into their trend line than countries with many surveys. For this report, country-level trends have been summarized into average trends for high-income countries, middle-income countries, low-income countries and a global average. Trends from 2007 to 2017 are presented, with projections of the same lines to 2030. The projection assumes that the pace and level of adoption of new policies during the period covered by the country’s surveys will continue unchanged. In future, when countries adopt stronger tobacco control policies and complete new surveys, recalculated trend lines will reflect the changes. In this report, comparable estimates of current tobacco smoking among people aged 15 years and over are presented for all countries in one year (2017). These rates are taken from the trend line for each country for the year 2017. The rates are comparable because the model has standardized the survey results as described above, and then age-standardized as described below. When calculating global and World Bank income group average prevalence rates, countries without estimates were included in the averages by assuming their prevalence rates are the average rates seen in the uN subregion to which they belong.3 age-standardized prevalence rates Comparison of crude rates between two or more countries at one point in time, or of one country at different points in time, can be misleading if the two populations being compared have significantly different age distributions or differences in tobacco use by sex. The method of age-standardization is commonly used to overcome this problem and allows for meaningful comparison of prevalence between countries, once all other comparison issues described have been addressed. The method involves applying the age-specific rates by sex in each population to one standard population (this report uses the WHO Standard Population, a fictitious population whose age distribution is largely reflective of the population age structure of low- and middle-income countries). The resulting age-standardized rates refer to the number of smokers per 100 WHO Standard Population. as a result, the rates generated using this process are only hypothetical numbers with no inherent meaning. They are only meaningful when comparing rates obtained from one country with those obtained in another country. Comparison with smoking estimates in earlier editions of this report The estimates in this report are consistent with each other but not with estimates produced for earlier editions of this report. While the method of estimation is the same, the updated data set for the period 1990–2018 is much more complete. For example, since the WHO report on the global tobacco epidemic, 2017, 242 national surveys from 89 countries have been added to the data set, and 46 existing surveys have been updated with additional data points. Each round of WHO estimates is calculated using all available survey data back to 1990. The more data points available, the more robust the trend estimates are. Each estimation round therefore improves upon earlier published estimates, and only the latest round should be used. While country-level estimates in this report pertain only to 2017, the entire trend series from 2000 to 2025 is published in the biennial WHO global report on trends in tobacco smoking 2000–2025. 1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by uN subregion, please refer to pages ix to xiii of World population prospects: the 2017 revision, published by the uN Department of Economic and Social affairs at https:// population.un.org/wpp/Publications/Files/WPP2017_ volume-I_Comprehensive-Tables.pdf (accessed april 17, 2019). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern africa subregion was divided into two regions: Eastern african Islands and remainder of Eastern africa; (ii) armenia, azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central africa and Southern africa were combined into one subregion; (v) melanesia, micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the united Kingdom were classified with Northern america. 136 137WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 This report includes appendices containing information on the share of total and excise taxes in the price of the most widely sold brand of cigarettes, based on tax policy information collected from each country. This note contains information on the methodology used by WHO to estimate the share of total and tobacco excise taxes in the price of a pack of 20 cigarettes using country-reported data. It also provides information on additional data collected for this report in relation to tobacco taxation. 1. Data collection all data were collected between June 2018 and January 2019 by WHO regional data collectors. The two main inputs into calculating the share of total and excise taxes were (1) prices and (2) tax rates and structure. Prices were collected for the most widely sold brand of cigarettes, the least-expensive brand and a premium brand for July 2018. Data on tax structure were collected through contacts with ministries of finance. The validity of this information was checked against other sources. For many countries, this was done through the wealth of work and knowledge accumulated by WHO working directly with ministries of finance on tobacco taxation since 2009. Other sources, including tax law documents, decrees and official schedules of tax rates and structures and trade information, when available, were either provided by data collectors or were downloaded from ministerial websites or from other databases such as the ImF or the World Bank. The tax data collected focus on indirect taxes levied on tobacco products (e.g. excise taxes of various types, import duties, value added taxes), which usually have the most significant impact on the price of tobacco products. Within indirect taxes, excise taxes are the most important because they are applied exclusively to tobacco TECHNICAL NOTE III Tobacco taxes in WHO Member states 1. Specific excise taxes a specific excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: uS$1.50 per pack of 20 cigarettes. 2. ad valorem excise taxes an ad valorem excise tax is a tax on a selected good produced for sale within a country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price. 3. Import duties an import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either amount-specific or ad valorem. amount-specific import duties are applied in the same way as amount-specific excise taxes. ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, (i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading). Example: 50% import duty levied on CIF. 4. value added taxes and sales taxes The value added tax (vaT) is a “multi-stage” tax on all consumer goods and services applied proportionally to the price the consumer pays for a product. although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. most countries that impose a vaT do so on a base that includes any excise tax and customs duty. Example: vaT representing 10% of the retail price. Some countries, however, impose sales taxes instead. unlike vaT, sales taxes are levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the vaT and/or sales tax shares were computed in accordance with country-specific rules. 5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, vaT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined. and contribute the most to increasing the price of tobacco products and subsequently reducing consumption. Thus, rates, amounts and point of application of excise taxes are central components of the data collected. Certain other taxes, in particular direct taxes such as corporate taxes, can potentially impact tobacco prices to the extent that producers pass them on to consumers. However, because of the practical difficulty of obtaining information on these taxes and the complexity in estimating their potential impact on price in a consistent manner across countries, they are not considered. The table below describes the types of tax information collected. 2. Data analysis The price of the most sold brand of cigarettes was considered in the calculation of the tax as a share of the retail price reported in appendix I and appendix Table 9.1. In the case of countries where different levels of taxes are applied on cigarettes based on length of cigarette, quantity produced, or type (e.g. filter vs. non-filter), only the relevant rate that applied to the most sold brand was used in the calculation. In the case of Canada and the united States of america, national average estimates calculated for prices and taxes reflect the fact that different rates are applied by state/province over and above the applicable federal tax. In the case of Brazil, where state vaTs vary, the highest rate, which is applied in most states, was applied. In the Federated States of micronesia, which also has varying vaT rates across states, the vaT rate applicable to the state where price data was collected (Pohnpei) was used. a weighted average of retail price and tax was calculated for China given the very large array of brands sold in the market: the most sold brand changing almost every year and representing a very small share of the market was not representative. The import duty was only used in the calculation of tax shares if the most sold brand of cigarettes was imported into the country. Import duty was not applied in the total tax calculation for countries reporting that the most sold brand, even if an international brand, was produced locally. In cases where the imported cigarettes originated from a country with which a bilateral or multilateral trade agreement waived the duty, care was taken to ensure that the import duty was not taken into account in calculating taxes levied. “Other taxes” are all other indirect taxes not reported as excise taxes, import duties or vaT. These taxes were, however, treated as excises if they had a special rate applied to tobacco products. For example, Thailand reported the tax earmarked from tobacco and alcohol for the ThaiHealth Promotion Foundation as “other tax”. However, since this tax is applied only on tobacco and alcohol products, it acts like an excise tax and so was considered an excise in the calculations. 3. Calculation Denote Sts as the share of taxes on the price of a widely consumed brand of cigarettes (20-cigarette pack or equivalent). Then, Sts = Sas + Sav + Sid + SVAT j Where: Sts = Total share of taxes in the price of a pack of cigarettes; Sas = Share of amount-specific excise taxes (or equivalent) in the price of a pack of cigarettes; Sav = Share of ad valorem excise taxes (or equivalent) in the price of a pack of cigarettes; Sid = Share of import duties in the price of a pack of cigarettes (if the most popular brand is imported); SVAT = Share of the value added tax in the price of a pack of cigarettes. Calculating Sas is fairly straightforward and involves dividing the specific tax amount for a 20-cigarette pack by the total price. unlike Sas, the share of ad valorem taxes, Sav is much more difficult to calculate and involves making some assumptions described below. Import duties are sometimes amount-specific, sometimes value-based. Sid is therefore calculated the same way as Sas if it is amount-specific and the same way as Sav if it is value-based. vaT rates reported for countries are usually applied on the vaT-exclusive retail sale price but are also sometimes reported on vaT-inclusive prices. SVAT is calculated to consistently reflect the share of the vaT in vaT-inclusive retail sale price. COUNTRy A (US$) COUNTRy B (US$) [a] manufacturer’s price (same in both countries) 2.00 2.00 [B] Country a: ad valorem tax on manufacturer’s price (20%) = 20% x [a] 0.40 - [C] Wholesalers’ and retailers’ profit margin (same in both countries) 0.20 0.20 [D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55 [E] Final price = P = [a]+[B]+[C] or [a]+[C]+[D] 2.60 2.75 Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 =20% The next step of the exercise was to convert all taxes to the same base – in our case, the tax- inclusive retail sale price (hereafter referred to as P). Standardizing bases is important in calculating tax share correctly, as the example in the table above shows. Country B apparently applies the same ad valorem tax rate (20%) as Country a, but in fact ends up with a higher tax rate and a higher final price because the tax is applied later in the distribution chain. Comparing reported statutory ad valorem tax rates without taking into account the stage at which the tax is applied could therefore lead to biased results. a similar methodology was used to calculate the price and tax share of the most common type of smoked (other than cigarettes) and smokeless tobacco products, as reported by each country. The calculation was made for the price of a product for 20 grams for any smoked or smokeless tobacco product except for cigars and cigarillos, for which the price and tax was reported per piece. Price and tax for smoked tobacco products (including bidis, cheroots, cigarillos, cigars, pipe tobacco, roll-your- own or waterpipe tobacco) was calculated for 70 countries, while the calculation for smokeless tobacco products (chewing tobacco, dry snuff, moist snuff nose tobacco or snus) was made for 27 countries (see Table 9.5 in online appendix IX). Price and tax for heated tobacco products (per 20 sticks) was also calculated but only for a very small number of countries that reported them (nine countries). 138 139WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The price of a pack of cigarettes can be expressed as the following: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) or P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + vaT%) k Where: P = Price per pack of 20 cigarettes of the most popular brand consumed locally; M = manufacturer’s/distributor’s price, or import price if the brand is imported; ID = Import duty rate (where applicable) on a pack of 20 cigarettes;1 Tav = Statutory rate of ad valorem tax; Tas = amount-specific excise tax on a pack of 20 cigarettes; π = retailers’, wholesalers’ and importers’ profits per pack of 20 cigarettes (sometimes expressed as a mark-up); VAT = Statutory rate of value added tax on vaT- exclusive price. Changes to this formula were made based on country-specific considerations such as the base for the ad valorem tax and excise tax, the existence – or not – of ad valorem and specific excise taxes, and whether the most popular brand was locally produced or imported. In many cases (particularly in low- and middle-income countries) the base for ad valorem excise tax was the manufacturer’s price or CIF value. But in fact, the base of the ad valorem varies a lot around the world and can include other bases, such as retail price, retail price net of some taxes (and/or some predefined margins), retail price net of all taxes, etc. Given knowledge of price (P) and amount-specific excise tax (T as), the share Sas is easy to recover (=Tas/P). The case of ad valorem taxes (and, where applicable, Sid) is fairly straightforward when, by law, the base is retail price (as is the case in several European union countries). The calculation is more complicated when retail price is not the base, because the base (m) needs to be recovered to calculate the amount of ad valorem tax. In most of the cases, m was not known (unless specifically reported by the country), and therefore had to be estimated. using equation (2), it is possible to recover m: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, or wholesalers’ and retailers’ profit margins, are rarely publicly disclosed and will vary from country to country. For domestically produced most popular brands, we considered π to be nil (i.e. = 0) in the calculation of m because the retailers’ and wholesalers’ profit margins are assumed to be small. Setting the margin to 0, however, would result in an overestimation of m and therefore of the base for the ad valorem tax. This will in turn result in an overestimation of the amount of ad valorem tax. Since the goal of this exercise is to measure how high the share of tobacco taxes is in the price of a typical pack of cigarettes, assuming that the retailer’s/wholesaler’s profit (π) is nil, therefore, does not penalize countries by underestimating their ad valorem taxes. Considering this, it was decided that unless country-specific information was made available to WHO, the retailer’s or wholesaler’s margin would be assumed to be nil for domestically produced brands. For countries where the most popular brand is imported, the import duty is applied on CIF values, and the consequent excise taxes are typically applied on a base that includes the CIF value and the import duty, but not the importer’s profit. For domestically produced cigarettes, the producer’s price includes its own profit, so it is automatically included in m. In practice, however, the importer’s profit can be relatively significant and setting it to zero (as in the case of domestically manufactured cigarettes) would substantially overestimate m, and thereby substantially overestimate the share of ad valorem tax in final price. For this reason, m had to be estimated differently for imported products: m* (or the CIF value) was calculated either based on information reported by countries or using secondary sources (data from the united Nations Comtrade database2). m* was normally calculated as the import price of cigarettes in a country (value of cigarette imports divided by the quantity of cigarette imports for the importing country). However, in exceptional cases where no such data were available (Democratic republic of the Congo, Equatorial Guinea, and Libya), the export price was considered instead (where the export price was considered too low – i.e. below uS$ 0.2 per pack – the value was approximated as the export price plus uS 10 cents). The ad valorem and other taxes were then calculated in the same way as for local cigarettes, using m* rather than m as the base, where applicable. In the case of vaT, in most of the cases the base was P excluding the vaT (or, similarly, the manufacturer’s/distributor’s price plus all excise taxes). In other words: SVAT = vaT% × (1 - SVAT), equivalent to m SVAT = vaT% ÷ (1+ vaT%) In some cases, however, we were informed that the vaT was not effectively collected at all levels of the supply chain and was mainly levied at the import or manufacturing point. In this case, the vaT was calculated on the basis of m (or m*) and the different taxes collected at this stage, mainly import duties and excise taxes (angola, Benin, Cabo verde, Cameroon, Cook Islands, Côte d’Ivoire, Equatorial Guinea, Ethiopia, Gabon, Gambia, Guinea-Bissau, Iran, Kiribati, mali, mauritania, Suriname, Tonga, Tuvalu, uganda, vanuatu and viet Nam). In sum, the tax rates are calculated this way: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav % × M) ÷ P or (Tav % × M*× (1+ Sid)) ÷ P 3 if the most popular brand was imported Sid = (TID % × M*) ÷ P (if the import duty is value-based) or ID ÷ P (if import duty is a specific amount per pack) SVAT = vaT% ÷ (1+ vaT%) 4. Prices Primary collection of price data in this and previous reports involved surveying retail outlets. Price data were collected in the following manner: • In addition to the most sold brand reported in previous years, there was a space provided for data collectors to report a new most sold brand - π -Tas in case the one collected in past years was not the most sold brand anymore. • For each brand, prices were required from two different types of retail outlets. Questionnaires sent to data collectors were pre-populated with the names of the highest selling brand in each country. The popular brand was identified using data collected from the 2016 questionnaires, from secondary data (Euromonitor4) and through WHO’s close collaboration with ministries of finance. For the countries where such data were not available, data collectors were asked to indicate the names of the popular brands and provide their prices. The two types of retail outlets were defined as follows: 1. Supermarket/hypermarket: chain or independent retail outlets with a selling space of over 2500 square metres and a primary focus on selling food/beverages/tobacco and other groceries. Hypermarkets also sell a range of non-grocery merchandise. 2. Kiosk/newsagent/tobacconist/independent food store: small convenience stores, retail outlets selling predominantly food, beverages and tobacco or a combination of these (e.g. kiosk, newsagent or tobacconist) or a wide range of predominantly grocery products (independent food stores or independent small grocers). most sold brands have been used consistently over time to gain a better reflection of the change in prices. However, in some cases where the market share of the brand initially used was considered to have changed substantially, a change was made to the new, more prevalent brand. In 2018, changes in the brand were made for antigua and Barbuda, australia, Benin, Cuba, Cyprus, Gabon, Gambia, Kazakhstan, Niger, Saint vincent and the Grenadines, Serbia, viet Nam (different brand but same price category), azerbaijan, Barbados, Belize, Brazil, Grenada, Nicaragua, Pakistan, Papua New Guinea, Peru, Thailand (cheaper brand), El Salvador, Bosnia and Herzegovina, mozambique (more expensive brand) and Turkmenistan (not possible to determine how the new brand compared to the previous one). In 11 other countries (austria, Bolivia (Plurinational State of),, Denmark, Hungary, Nauru, Panama, Poland, romania, Slovakia, Spain and Sweden) the brand reported in 2018 was a variant of the brand reported in 2016, and these were treated as identical in both years for purposes of price comparisons. as in 2012, 2014 and 2016, the price used for each of the 28 countries of the European union (Eu)5 was the most sold brand collected by WHO. Prior to 2012, price and tax information were taken entirely from the Eu’s Taxation and Customs union website. The price used by the Eu in the past to calculate tax rates was the most popular price category (mPPC), which was assumed to be similar to the most sold brand price category collected in this report. However, since 2011, the Eu calculates and reports tax rates based on the Weighted average Price (WaP) and therefore information on the mPPC is no longer readily available for Eu countries. Consequently, in order to be consistent with past years’ estimates and to ensure comparability with other countries, WHO decided in 2012 to collect first-hand prices of the most sold brand (the brand was determined based on brand market shares reported from secondary sources) to calculate tax rates. Excise and vaT rates are still collected from the Eu published tables. This means, however, that tax shares as computed and reported in this report will not necessarily be similar to the rates published by the Eu. This is mainly due to the calculation of the specific excise tax rates as a percentage of the retail price, which will vary depending on the price used. See details of the difference in price and tax share for the Eu countries in the table (left). Total tax share (% of retail price) Retail price (20 cigarettes) Country WHO estimates EU reported rates WHO reported MSB EU reported WAP Currency austria 75.3% 78.53% 5.50 4.76 Eur Belgium 77.0% 79.37% 6.60 5.88 Eur Bulgaria 83.6% 85.09% 5.20 5.02 BGN Croatia 78.8% 79.91% 25.00 23.93 HrK Cyprus 74.4% 75.67% 4.50 4.28 Eur Czechia 75.4% 78.31% 94.00 86.00 CZK Denmark 74.1% 79.89% 44.50 40.16 DKK Estonia 79.4% 85.82% 4.25 3.55 Eur Finland 87.4% 88.67% 7.22 6.70 Eur France 82.4% 85.07% 8.00 6.81 Eur Germany 68.3% 72.49% 6.40 5.64 Eur Greece 81.2% 85.64% 4.60 4.10 Eur Hungary 72.3% 75.22% 1,245.00 1,118.72 HuF Ireland 78.4% 89.12% 12.20 10.07 Eur Italy 76.0% 77.13% 5.50 4.76 Eur Latvia 80.0% 83.99% 3.50 3.20 Eur Lithuania 73.8% 79.46% 3.75 3.18 Eur Luxembourg 68.3% 69.40% 5.30 4.60 Eur malta 77.6% 79.40% 5.50 5.25 Eur Netherlands 71.8% 78.29% 7.00 6.19 Eur Poland 76.8% 80.04% 15.50 13.82 PLN Portugal 71.7% 76.16% 5.00 4.47 Eur romania 68.6% 72.56% 17.50 15.86 rON Slovakia 77.1% 77.88% 3.30 3.23 Eur Slovenia 79.2% 81.28% 3.70 3.51 Eur Spain 78.2% 79.28% 5.00 4.52 Eur Sweden 68.4% 74.16% 65.00 57.94 SEK united Kingdom of Great Britain and Northern Ireland 79.4% 88.80% 9.40 7.81 GBP Comparisons of prices and total tax shares are computed from WHO’s most sold brand (MSB) survey and EU weighted average price (WAP). Note: WHO estimates pertain to most sold brand prices collected in July 2018. Eu reported rates and weighted average prices pertain to data collected by the Eu and are also reported for July 2018. as indicated earlier, the most sold brand was used for all Eu countries except for Finland, which reported directly to WHO its weighted average price (WaP) for 2008, 2010, 2012, 2014, 2016 and 2018. The 2018 data shows a different WaP for WHO compared to the Eu reported WaP for Finland. This is because the price reported to WHO was an estimate updated in 2019, while the Eu reported WaP was collected in 2018. 140 141WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 5. Considerations in interpreting tax share changes Changes in tax as a share of price are not only dependent on tax changes but also on price changes. Therefore, despite an increase in tax, the tax share could remain the same or go down; similarly, sometimes a tax share can increase even if there is no change/increase in the tax. In the current database, there are cases where taxes increased between 2016 and 2018 but the share of tax as a percentage of the price went down. This is mainly due to the fact that, in absolute terms, the price increase was larger than the tax increase (particularly in the case of specific excise tax increases). For example, in mongolia, the specific excise tax increased from 3480 mNT per 100 cigarettes in 2016 to 3830 mNT per 100 cigarettes in 2016 (a 10% increase) while the price of the most sold brand increased from 1700 to 2000 mNT per pack (an 18% increase). In terms of tax share, the excise represented 52.9% of the price in 2016 and went down to 47.4% of the price in 2018. This is because prices rose more than taxes. In the same way there are cases where increases (decreases) in tax as a share of price were mitigated by factors not directly related to tax rates. In the current database, this was attributable to one or more of the following reasons: • In some instances, the price increased without a tax change, leading to a decrease in the tax share for a specific or mixed excise structure (e.g. China, Cyprus, Denmark, Dominica, Ecuador, Germany, Israel, mexico, Palau, Poland, Saint vincent and the Grenadines, Switzerland, Timor-Leste, Tunisia, and yemen). • In other cases, prices increased above tax increases, leading to a decrease in tax share for a specific or mixed excise structure (e.g. algeria, austria, Canada, Chile, Cook Islands, Costa rica, Czechia, Dominican republic, Gambia, Grenada, Honduras, Hungary, Iceland, Iran (Islamic republic of), Jamaica, Jordan, Lithuania, Luxembourg, malta, mongolia, Norway, Portugal, republic of moldova, romania, Samoa, Serbia, Seychelles, Slovakia, Spain, Suriname, Sweden, Tonga, Trinidad and Tobago, Turkey, uganda, ukraine, united Kingdom of Great Britain and Northern Ireland, united republic of Tanzania, united States of america). • In the case of imported products, the CIF value is an external variable that also influences the calculation of tax share. This has implications in countries where ad valorem is based on the CIF value, when import duties are applicable on the CIF value or when the vaT is calculated on the base of CIF value and excise rather than vaT-exclusive retail price. For example, if the CIF value increases, the base for the application of the tax is higher, leading to a higher tax percentage if nothing else changes. Countries that have seen changes in their tax share mainly due to changes in CIF value include Togo, Libya and micronesia (Federated States of). • Care should also be taken in relation to countries where the most sold brand changed between 2016 and 2018. This also has had an impact on the tax proportion of the affected countries that had a specific or mixed excise structure. In some cases, because the new brand reported was more expensive and despite tax increases, the total tax share decreased (Bosnia and Herzegovina, mozambique and Peru). In the case of El Salvador, the tax proportion decreased despite no tax change, because of the apparent increase in prices due to the new, more expensive brand reported as the most sold brand. In one other case (Belize), the new brand reported was cheaper, so the tax share increased despite no tax increase. Finally, when new and improved information was provided in terms of taxation and prices for some countries, corrections were made in the calculations of tax rates for 2008, 2010, 2012, 2014 and 2016 estimates, as needed. 6. Supplementary tax information (see Table 9.3, online Appendix IX) an important consideration highlighted in this report is that many aspects of tobacco taxation need to be taken into account in order to assess if a tax policy is well designed. Tax as a proportion of price does not tell the whole story about the effectiveness of a tax policy. To explore other dimensions of tax policy, the report has been collecting since 2015 additional information in relation to tobacco taxation and presents it as data that can inform researchers and policy- makers further on tax policy in different countries. The information is compiled and classified in this report according to two main themes: tax structure/level and tax administration. Information was also collected in relation to countries that earmark tobacco taxes to fund health programmes and/or tobacco control activities. The different sets of data/indicators reported under each of the themes were developed and are justified based on evidence provided in past reports. I. Tax structure/level a. Excise tax proportion of price: higher tax rates and greater reliance on excise is better. b. Type of excise applied: if excise tax is specific, ad valorem, a mix of the two, or if no excise is applied. c. Uniform vs. tiered excise tax system: a uniform excise is easier to administer than a tiered system where variable rates apply based on selected criteria within one tobacco product (not applicable in countries where no excise tax is implemented). d. Whether a country applies a specific excise or a mixed system relying more on the specific tax component (> 50% of total excise is specific): specific excises typically lead to higher prices and a smaller price gap between different brands, and so are more effective (not applicable in countries where only ad valorem excise is applicable or where no excise tax is implemented). e. If the excise applied is ad valorem or if it is mixed, and whether there is a minimum specific tax. a minimum tax provides protection against products being undervalued. It also forces prices up since the price will not be lower than the tax paid (this category does not apply to countries where only specific excise tax is applicable or where no excise tax is implemented). f. Base of the ad valorem tax in countries that apply an ad valorem or a mixed excise system. Ad valorem taxes applied to the retail price or the retail price excluding vaT are administratively simpler. The retail price is easier to determine than producer price or CIF value, and therefore there is less risk of undervaluation (not applicable in countries where only specific excise is applicable, or where no excise tax is implemented). g. If the excise tax applied is specific or if it is mixed, and whether the specific tax component is automatically adjusted for inflation (or other). If the specific tax is not adjusted for inflation (or another indicator such as income) over time, its impact will be eroded. It is good to have it adjusted automatically (this category does not apply to countries where only ad valorem excise tax is applicable or where no excise tax is implemented). h. minimum price policy: while this is not reported as a best practice, it was considered important to report the countries that did impose minimum prices as part of their excise tax policy. i. Price dispersion: share of cheapest brand price in premium brand price (cheapest brand price ÷ premium brand price × 100). The higher the proportion, the smaller the gap and the fewer the opportunities for substitution to cheaper brands. II. Tax administration a. requirement of tax stamps (or fiscal marks) on tobacco products: tax stamps help administrators ensure that producers and importers comply with tax payment requirements and help detect illicit tobacco products. a note was made of countries requiring tax stamps to bear special features beyond those found on traditional paper stamps. Specifically, these are encrypted tax stamps that include unique identifiers used to detect the presence of illicit products. Data was collected to identify which countries had an additional feature on those marks which was used for tracking and tracing purposes. b. Sales of duty free cigarettes: In most countries tobacco products are found to be sold without excise (and other indirect taxes such as vaT and import duties) in duty-free shops in airports, on international transport vehicles and/or other tax-free shops. Duty-free tobacco products are usually made available to travellers going out of the country, but they are now also made available for travellers entering a country. Banning the sale of duty-free cigarettes for personal consumption reduces the chance that these products end up in the illicit market. additionally, there is no justification for selling a deadly product duty-free; those foregone taxes are a revenue loss for the government. Some countries have already acted and have banned the sale of duty-free tobacco products. Those products may still be found in airport and other tax-free shops, but they are sold with (excise) taxes included. III. Earmarking (portion of taxes or revenues from taxes dedicated to health and/or tobacco control). Taxes can generate substantial revenues. One way of correcting the negative externality of tobacco use would be to increase taxes to reduce consumption and fund health care, which is often underfunded and put under strain because of tobacco use (see Table 9.4 in online appendix IX). 7. Estimates of the affordability of cigarettes (see Table 9.5, online Appendix IX) The affordability of cigarettes for each of the years 2008, 2010, 2012, 2014, 2016 and 2018 was measured by the per capita GDP required to purchase 2000 cigarettes of the most sold brand reported in that year. analysis of affordability in this report informs the following: • affordability index (% of GDP per capita to buy 2000 cigarettes): across countries, a higher value indicates cigarettes are relatively more expensive in relation to income. • Whether cigarettes have become relatively more affordable between 2008 and 2018 (change in the affordability index as measured above): as affordability decreases, consumption is discouraged. Estimates of GDP per capita in local currency units were sourced from the ImF’s World Economic Outlook (WEO) database which provides a complete series of estimates for most of the 195 countries reported on. Where GDP per capita data were not available in the WEO database, (andorra, Cuba, occupied Palestinian territory, including east Jerusalem, and Somalia), the World Bank’s GDP per capita data series was used. In the case of the Cook Islands, government data was used. For each country–year pair, the currency reported for the most sold brand was tallied with the corresponding currency for the GDP series, and exchange rate conversions and adjustments were performed as needed (Belarus, Cambodia, Estonia, Latvia, Liberia Lithuania, Turkmenistan, Zambia) to align the two data series. To assess whether affordability changed on average since 2008, the average annual percentage change in affordability was calculated as the least squares growth rate for all countries with four or more years of data, including data for 2018. This criterion automatically excluded countries where World Bank GDP per capita estimates were used, given that the series ended with the year 2017 at the time the analysis was performed. The affordability of cigarettes was judged to have been unchanged if the least squares trend in the per capita GDP required to purchase 2000 cigarettes (that is, 100 packs of 20 cigarettes) was not significant at the 5% level. Cigarettes were judged to have become less (more) affordable on average if the least squares trend in the per capita GDP required to purchase 2000 cigarettes was positive (negative) and significantly different from zero at the 5% level. 1 Import duties may vary depending on the country of origin in cases of preferential trade agreements. WHO tried to determine the origin of the pack and relevance of using such rates where possible. 2 https://comtrade.un.org/ 3 Or Sav = (Tav % × m*) ÷ P, if the ad valorem tax was applied only on the CIF value, not the CIF value + the import duty. 4 Euromonitor International’s Passport, 2018. 5 Except for Finland where the weighted average price of cigarettes was used for years 2008, 2010, 2012, 2014, 2016 and 2018. 142 143WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix I provides an overview of selected tobacco control policies. For each WHO region an overview table is presented that includes information on monitoring and prevalence, smoke-free environments, treatment of tobacco dependence, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, taxation levels, and affordability of tobacco products, based on the methodology outlined in Technical Note I. Country-level data were generally but not always provided with supporting documents such as laws, regulations, policy documents, etc. Available documents were assessed by WHO and this appendix provides summary measures or indicators of country achievements for each of the MPOWER measures. Detailed information, including detailed footnotes on each of the indicators, is available in Appendix II for tobacco dependence treatment, in Appendix VI for smoke- free environments, health warnings and packaging, anti-tobacco mass media campaigns, advertising, promotion and sponsorship bans, and in Appendix IX for tobacco taxation and affordability. It is important to note that data about laws reflect the status of legislation adopted by 31 December 2018 which has a stated date of effect and is not undergoing a legal challenge that could impact the date of implementation. REGIONAl SUMMARy OF MPOWER MEASURES Appendix i: The summary measures developed for the WHO report on the global tobacco epidemic, 2019 are the same as those used for the 2017 report. The methodology used to calculate each indicator is described in Technical Note I. This review, however, does not constitute a thorough and complete legal analysis of each country’s legislation. Except for smoke-free environments and bans on tobacco advertising, promotion and sponsorship, data were collected at the national/ federal level only and therefore provide incomplete policy coverage for Member States where subnational governments play an active role in tobacco control. Daily smoking prevalence for the population aged 15 years and over in 2017 is an indicator modelled by WHO from tobacco use surveys published by Member States. Tobacco smoking is one of the most widely reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II. 144 145WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 1.1 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Algeria 12% IIIII IIIII 34.2% YES Angola . . . . . . — 23.7% YES p Benin 5% IIIII IIIIIIII 4.9% NO p q p Botswana 15% — . . . 49.9% ↔ p Burkina Faso 11% IIII IIIIII 41.6% ↔ Burundi 7% — — 42.8% ↔ p p p Cabo Verde . . . IIIII IIIIIII 11.2% NO Cameroon 6% . . . 8 . . . 21.3% NO p Central African Republic . . . — — 41.5% ↔ q Chad 7% III IIIIIII 34.1% YES Comoros 11% III IIIIII 37.3% ↔ p Congo 9% I IIIIIIII 37.1% ↔ p Côte d'Ivoire 9% — — 33.3% NO Democratic Republic of the Congo . . . 8 — 8 38.7% NO p p Equatorial Guinea . . . — — 25.3% ↔ Eritrea 5% — . . . 55.4% ↔ Eswatini 6% — IIIIIIIIII 52.7% NO p Ethiopia 2% IIIII I IIIII 18.8% NO Gabon . . . IIIII IIIIIII 23.1% ↔ q Gambia 10% — IIIIIII 46.3% YES p p q Ghana 3% — I IIIIIIII 31.3% NO Guinea . . . . . . . . . … … q Guinea-Bissau . . . . . — — 6.8% ↔ q Kenya 8% — IIIIIIIIII 52.3% NO Lesotho 21% . . . — 50.9% NO Liberia 6% — — 34.8% ↔ p Madagascar 16% IIII IIIIIIIII 80.4% YES Malawi 8% — — . . . . . . Mali 10% — IIIIIII 27.7% NO Mauritania . . . I 8 — 9.6% NO p p Mauritius 16% IIIIII IIIIIIIII 83.5% YES p Mozambique 11% IIIIIIIIII 28.5% YES p Namibia 13% IIIIII IIIIIIIIII 44.1% ↔ Niger 5% III IIIIIIIII 31.3% ↔ Nigeria 3% — III 29.7% NO p Rwanda 9% — IIIIIIII 55.9% NO q Sao Tome and Principe 4% — I IIIIIIIII 40.4% NO q Senegal 6% IIII I IIIIII 38.2% YES Seychelles 16% IIIIIIIIII IIIIIIIIII 70.1% ↔ Sierra Leone 19% — — 18.6% ↔ South Africa 17% — . . . 54.6% ↔ p South Sudan . . . — — . . . . . . Togo 6% IIIIIIIIII I IIIIIIIIII 22.0% ↔ Uganda 5% III IIIIIII 39.9% YES q United Republic of Tanzania 8% — I . . . 32.1% ↔ q Zambia 10% III — 41.2% ↔ p Zimbabwe 11% IIII — 35.9% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 146 147WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 1.2 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The Government of Canada has not implemented a nationwide mass media campaign during the reporting period. However, mass media campaigns have been implemented in three of Canada’s provinces. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Antigua and Barbuda . . . I — 13.3% ↔ p p p Argentina 16% IIIIIIII IIIIIIII 76.2% YES Bahamas 8% — . . . . . . . . . Barbados 5% IIIIIIIIII — 47.1% YES p Belize . . . — — 43.6% NO Bolivia (Plurinational State of) . . . II II 36.8% ↔ q Brazil 11% IIIIIIIIII IIIIIIIII 83.0% ↔ p Canada1 10% IIIIIIIII IIIIIIIIII 64.3% YES Chile 32% IIIIIIII IIIIIIIII 82.4% YES Colombia 5% IIIIIII IIIIIII 78.4% ↔ p Costa Rica 6% IIIII IIIIII 55.1% YES Cuba 19% IIII — 70.2% . . . Dominica . . . — — 23.6% ↔ q Dominican Republic 7% III — 51.1% NO Ecuador . . . IIIIIIII IIIIIII 70.0% YES El Salvador 6% III IIIIIII 47.5% ↔ q Grenada . . . — — 44.0% ↔ Guatemala . . . IIIII III 49.0% ↔ Guyana 11% IIIIIII 8 IIIIII 27.5% NO p p p p Haiti 6% — — . . . . . . Honduras . . . IIIIIIIIII IIIIII 33.4% YES p Jamaica 8% IIIIIIII IIIIIIII 43.6% YES Mexico 8% IIII I IIII IIIII 67.0% ↔ Nicaragua . . . IIIII IIIIIII 40.2% ↔ Panama 3% IIIIIII IIIIIII 56.5% ↔ q Paraguay 9% IIIII IIIII 17.4% ↔ p Peru 7% IIIIII IIIIII 49.0% YES Saint Kitts and Nevis . . . — — 19.8% ↔ Saint Lucia . . . . . . — 51.2% ↔ p Saint Vincent and the Grenadines . . . — — 16.9% ↔ Suriname . . . IIIII IIIIIIII 47.6% YES q Trinidad and Tobago . . . IIIIIIIII 8 IIIIIIII 25.7% YES United States of America 14% . . . . . . 43.0% ↔ Uruguay 18% IIIIIIIII IIIIIIII 66.1% ↔ Venezuela (Bolivarian Republic of) . . . IIIIIIII IIIIIIIIII 73.0% . . . ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 148 149WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 South-East Asia Table 1.3 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The manufacture and sale of tobacco products are banned. However all tobacco products imported for personal consumption shall show the country of origin and health warnings. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Bangladesh 19% IIIIII IIIIII 71.0% YES Bhutan1 . . . IIIIIIIIII IIIIIIIIII — — Democratic People's Republic of Korea 13% IIIII — 0.0% . . . India 10% IIIIIII I IIIIIII 54.0% YES Indonesia 28% IIII 58.5% ↔ Maldives . . . I IIII 68.7% YES Myanmar 16% IIIII IIIIII 32.5% NO Nepal 15% IIIII IIIIIIII 30.0% ↔ Sri Lanka 10% IIIIIIII IIIIIIIII 66.2% YES Thailand 17% IIIII IIIIII 78.6% ↔ p Timor-Leste 28% IIIIII IIIIIIII 21.8% YES p p q ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 150 151WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe Table 1.4 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 1 The reported compliance is a calculated average of the assessment from two experts from the Federation of Bosnia and Herzegovina, and one expert from Republika Srpska. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Albania 23% IIIII IIIIIIIII 67.2% YES Andorra 28% IIIIIII I — 79.3% . . . p Armenia 25% III IIII 38.1% NO Austria 23% IIIII IIIIIIIII 75.3% YES Azerbaijan 17% III I IIIIIIII 35.3% ↔ p p Belarus 24% — IIIIII 50.9% YES p Belgium 21% IIIIIIII I IIIIIIIII 77.0% YES Bosnia and Herzegovina1 32% — IIIIIII 83.8% YES Bulgaria 31% IIIIIII IIIIIIII 83.6% ↔ Croatia 30% IIIIIIIII I IIIIIIIII 78.8% YES p p Cyprus 30% . . . . . . 74.4% YES p q Czechia 24% IIIIIIII IIIIIIIII 75.4% YES p Denmark 15% IIIIIIII IIIIIII 74.1% ↔ Estonia 24% IIIIII IIIIIIII 79.4% YES q Finland 15% IIIIIIIIII IIIIIIIIII 87.4% YES France 28% IIII I IIIIIIIII 82.4% YES Georgia 25% — IIIIIII 71.2% ↔ p p p Germany 22% — IIIIIII 68.3% YES Greece 31% IIIIIIIII IIIIIII 81.2% YES Hungary 26% IIIIIIIIII IIIIIIIIII 72.3% YES Iceland 11% IIIIIIIIII IIIIIIIIII 55.5% ↔ Ireland 20% IIIIIIIIII IIIIIIIII 78.4% ↔ Israel 21% . . . . . . 75.9% YES q Italy 19% — I IIIIIIII 76.0% YES Kazakhstan 17% IIIIIIII IIIIIIII 52.4% YES p Kyrgyzstan 21% II IIII 48.6% ↔ Latvia 31% IIIIIIIII IIIIIIIIII 80.0% ↔ Lithuania 22% IIIIIIII IIIIIIIIII 73.8% ↔ q Luxembourg 17% IIIIIIIII I IIIIIIIIII 68.3% YES p p Malta 20% IIIIIIII IIIIIIIIII 77.6% NO q Monaco . . . . . .I IIII — . . . . . . Montenegro . . . II IIIIII 81.4% YES q p Netherlands 18% — IIIIIIIII 71.8% YES North Macedonia . . . IIIIIII IIIIIIIII 81.3% ↔ p Norway 13% IIIIIIIIII IIIIIIIIII 64.0% YES Poland 23% … . . . 76.8% YES Portugal 22% IIIIIII I IIIIII 71.7% YES Republic of Moldova 21% IIIIIII IIIIIII 58.0% YES Romania 23% IIIIIIII IIIIIIIII 68.6% ↔ Russian Federation 27% IIIIII IIIIIII 57.7% YES San Marino . . . . . . I . . . . . . . . . q Serbia 33% IIII IIIIII 77.3% YES Slovakia 24% IIIIIIII IIIIIIIIII 77.1% YES p Slovenia 20% IIIIIIIII I IIIIIIIIII 79.2% YES p p Spain 24% IIIIIIIII IIIIIIII 78.2% YES p Sweden 10% — . . . 68.4% YES p Switzerland 20% — IIIIII 60.3% YES Tajikistan . . . IIII IIIIIII 42.3% ↔ p q p Turkey 25% IIIIIII IIIIII 81.4% YES Turkmenistan . . . IIIIIIII IIIIIIIIII 32.4% YES Ukraine 23% IIIIIII IIIIIIII 74.7% YES q United Kingdom of Great Britain and Northern Ireland 17% IIIIIIIIII . . . 79.4% YES Uzbekistan 10% IIII IIIIIIII 44.7% ↔ ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 152 153WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean Table 1.5 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. 1 The reported compliance is a calculated average of the assessment from experts from the West Bank. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Afghanistan . . . IIIIII 4.1% YES q Bahrain 15% — I IIIIIIIII 64.5% YES p Djibouti . . . . . . . . . . . . . . . q Egypt 19% III IIIIIII 77.2% YES p Iran (Islamic Republic of) 9% IIIIIIII IIIIIIIIII 21.7% YES q q Iraq 16% III IIII 7.6% ↔ Jordan . . . III IIIII 80.5% YES Kuwait 16% . . . . . . 21.2% YES Lebanon 24% III IIIIII 45.6% ↔ Libya . . . III IIIIIIII 12.6% YES Morocco 12% III IIIIII 71.2% NO Oman 6% — IIIIIIII 25.0% YES q p Pakistan 13% III 8 IIIII 56.4% ↔ p Qatar 11% — IIIIIIIIII 40.0% YES p Saudi Arabia 11% IIIIIII I 8 IIIIIII 68.1% YES p p p p Somalia . . . — — 4.5% . . . Sudan . . . — IIIIIIIII 69.8% ↔ p Syrian Arab Republic . . . III IIIIIIIIII 41.8% . . . Tunisia 20% — IIIIIIII 72.0% ↔ United Arab Emirates 12% IIIIIIIII I IIIIIIIIIII IIIIIIIII 73.5% YES p West Bank and Gaza Strip <1 . . . III IIIIIIII 83.5% . . . Yemen 13% IIIII IIIIII 50.6% YES ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 154 155WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific Table 1.6 Summary of MPOWER measures . . . Data not reported/not available. — Data not required/not applicable. 2018 INDICATOR AND COMPLIANCE CHANGE SINCE 2016 COUNTRy ADULT DAILy SMOKING PREvALENCE (2017) M MONITORING P SMOKE-FREE POLICIES O CESSATION W WARNINGS E ADvERTISING BANS R P SMOKE-FREE POLICIES O CESSATION PROGRAMMES W HEALTH WARNINGS E ADvERTISING BANS R TAxATION LINES REPRESENT LEVEL OF COMPLIANCE HEALTH WARNINGS MASS MEDIA LINES REPRESENT LEVEL OF COMPLIANCE TAXATION CIGARETTES LESS AFFORDABLE SINCE 2008 CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2016 Australia 13% . . . IIIIIIIIII 77.5% YES p Brunei Darussalam 12% IIIIIII IIIIIIIIII — — q Cambodia 16% III IIIIIIIII 25.1% NO China 22% IIIII IIIIIII 55.7% NO Cook Islands 19% IIIIIIIIII IIIIIIIIII 70.3% YES Fiji 17% IIIIIIII IIIIIIIII 42.1% YES Japan 19% — 8 — 63.1% YES p Kiribati 45% IIIII IIIIIIIII 41.7% NO Lao People's Democratic Republic 24% IIIII IIIIIIII 18.8% NO Malaysia 18% — IIIII 58.6% YES Marshall Islands . . . IIIIIII IIIIIIIIII 54.1% NO Micronesia (Federated States of) . . . IIIIIIII — 48.6% YES q Mongolia 22% IIIII IIIIIIII 47.4% ↔ q Nauru 38% . . . . . . 48.3% YES q New Zealand 14% IIIIIIIIII IIIIIIIIII 82.2% YES p Niue . . . — 8 8 — 8 87.7% . . . p p p Palau 15% IIIIIII IIIIIIIII 73.0% ↔ Papua New Guinea . . . . . . . . . 54.2% ↔ p p p Philippines 19% IIIII IIIII 71.3% YES Republic of Korea 21% IIIIIIII . . . 73.8% ↔ Samoa 23% III IIIIIIIII 49.5% YES q Singapore 13% IIIIIIII I IIIIIIIIII 67.1% NO Solomon Islands 30% IIIIIIIIII 34.1% ↔ Tonga 26% IIIIIII IIIIIIIIII 62.4% YES Tuvalu 30% IIIIIII IIIIIIII 29.5% ↔ q q Vanuatu 13% — IIIIIIIII 58.6% NO Viet Nam . . . III IIIIIIII 36.7% NO p ADULT DAILy SMOKING PREvALENCE: AGE- STANDARDIZED* PREvALENCE RATES FOR ADULT DAILy SMOKERS OF TOBACCO (BOTH SExES COMBINED), 2017 . . . Estimates not available 30% or more From 20% to 29.9% From 15% to 19.9% Less than 15% * The figures should be used strictly for the purpose of drawing comparisons across countries and must not be used to estimate absolute number of daily tobacco smokers in a country. MONITORING: PREvALENCE DATA No known data or no recent data or data that are not both recent and representative recent and representative data for either adults or youth recent and representative data for both adults and youth recent, representative and periodic data for both adults and youth SMOKE-FREE ENvIRONMENTS: SMOKING BANS Data not reported/not categorized Complete absence of ban, or up to two public places completely smoke-free Three to five public places completely smoke-free Six to seven public places completely smoke-free all public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation) CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE Data not reported None NrT and/or some cessation services (neither cost-covered) NrT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NrT and some cessation services cost-covered HEALTH WARNINGS: HEALTH WARNINGS ON CIGARETTE PACKAGES Data not reported No warnings or small warnings medium size warnings missing some or many appropriate characteristics Or large warnings missing many appropriate characteristics medium size warnings with all appropriate characteristics Or large warnings missing some appropriate characteristics Large warnings with all appropriate characteristics MASS MEDIA: ANTI-TOBACCO CAMPAIGNS Data not reported No national campaign conducted between July 2016 and June 2018 with duration of at least three weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics, or with seven characteristics excluding airing on television and/or radio National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio ADvERTISING BANS: BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP Data not reported Complete absence of ban, or ban that does not cover national television, radio and print media Ban on national television, radio and print media only Ban on national television, radio and print media as well as on some but not all other forms of direct and/or indirect advertising Ban on all forms of direct and indirect advertising (or at least 90% of the population covered by subnational legislation completely banning tobacco advertising, promotion and sponsorship) TAxATION: SHARE OF TOTAL TAxES IN THE RETAIL PRICE OF THE MOST WIDELy SOLD BRAND OF CIGARETTES Data not reported < 25% of retail price is tax ≥25% and <50% of retail price is tax ≥50% and <75% of retail price is tax ≥75% of retail price is tax AFFORDABILITy OF CIGARETTES YES Cigarettes less affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand increased on average between 2008 and 2018 NO Cigarettes more affordable – per capita GDP needed to buy 2000 cigarettes of the most sold brand declined on average between 2008 and 2018 ↔ No trend change in affordability of cigarettes since 2008 . . . Insufficient data to conduct a trend analysis COMPLIANCE: COMPLIANCE WITH BANS ON ADvERTISING, PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS |||||||||| ||||||||| |||||||| High compliance (8/10 to 10/10) ||||||| |||||| ||||| |||| ||| moderate compliance (3/10 to 7/10) || | minimal compliance (0/10 to 2/10) SyMBOLS LEGEND I Country has one or more public places where designated smoking rooms (DSrs) are allowed. Separate, completely enclosed smoking rooms are allowed if they are separately ventilated to the outside and/or kept under negative air pressure in relation to the surrounding areas. Given the difficulty of meeting the very strict requirements delineated for such rooms, they appear to be a practical impossibility but no reliable empirical evidence is presently available to ascertain whether they have been constructed. 8 Policy adopted but not implemented by 31 December 2018. st Change in POWEr indicator group, up or down, between 2016 and 2018. Some 2016 data were revised in 2018. 2018 grouping rules were applied to both years. PLEASE REFER TO TECHNICAL NOTE I FOR DEFINITIONS OF CATEGORIES 156 157WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix II provides detailed information on tobacco dependence treatment availability in WHO Member States for each WHO region. Data in the appendix were provided by Member States and were reviewed by WHO. The following data are reported in this appendix: The available support for the treatment of tobacco dependence: l The existence of a national toll-free quit line l The existence of smoking cessation support in health facilities and other settings, and whether it is provided as a cost-covered service l The availability of nicotine replacement therapy and whether it is cost-covered TOBACCO DEPENDENCE TREATMENTAppendix ii: Policies and guidelines: The availability of national policies and clinical guidelines on tobacco cessation Integrating cessation into other tobacco control approaches: The integration of national toll-free quit lines into mass media campaigns and tobacco-related health warnings structural capacity: The existence of regular training programmes in tobacco cessation for primary care providers and the routine recording of tobacco use status in medical records 158 159WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Algeria No Pharmacy No Yes Yes in some No Yes in some No Yes in some No No — No — Angola No Not available — — Yes in some Fully Yes in some Fully Yes in some Fully No — No — Benin No Not available — No No — No — No — No — No — Botswana No Pharmacy with Rx No . . . Yes in some Fully No — No — Yes in some No Yes in some No Burkina Faso No Not available — No No — No — No — Yes in some . . . No — Burundi No Not available — No No — No — No — No — No — Cabo Verde No Not available — No No — No — No — Yes in some . . . Yes in some Partially Cameroon Yes . . . No No No — No — Yes in some Partially No — Yes in some Partially Central African Republic No Not available — No No — No — No — No — No — Chad No . . . No No No — No — No — Yes in some No No — Comoros No Not available — No No — No — Yes in some No . . . . . . Yes in some No Congo No Pharmacy Partially No No — Yes in some No Yes in some No Yes in some No Yes in some No Côte d'Ivoire Yes Pharmacy Partially No Yes in some No Yes in some No No — Yes in some No Yes in some No Democratic Republic of the Congo No Pharmacy No No No — No — Yes in some No No — No — Equatorial Guinea No Not available — . . . No — No — No — No — No — Eritrea No Not available — No No — No — No — No — No — Eswatini No Pharmacy with Rx Fully No No — No — No — No — No — Ethiopia No . . . Partially Yes No — No — No — No — Yes in some Partially Gabon No Pharmacy No No No — No — No — No — No — Gambia No Not available — No No — No — No — No — . . . . . . Ghana No Not available — No No — Yes in some Partially Yes in some No No — No — Guinea No Not available — No No — No — No — No — No — Guinea-Bissau No Not available — No No — No — No — No — No — Kenya Yes Pharmacy No No No — Yes in some Partially No — Yes in some . . . Yes in some Partially Lesotho No Pharmacy with Rx No No No — No — Yes in most Fully Yes in some No Yes in most Partially Liberia No Not available — No Yes in some No No — Yes in some No No — No — Madagascar No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Malawi No Not available — No No — No — No — No — No — Mali No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially No — No — Mauritania No Not available — No No — No — No — No — No — Mauritius No Pharmacy Fully No No — No — Yes in most No No — Yes in some Fully Mozambique No Not available — . . . Yes in some Partially Yes in some Partially No — Yes in some . . . No — Namibia No Pharmacy No . . . Yes in some Partially Yes in some No Yes in some No No — Yes in some Partially Niger No Pharmacy No No No — No — No — No — No — Nigeria No Pharmacy Partially No No — Yes in some Partially Yes in some Partially No — Yes in some Partially Rwanda No Not available — No No — No — No — No — No — Sao Tome and Principe No Not available — No No — No — No — No — No — Senegal Yes Pharmacy with Rx Partially No Yes in some Partially No — Yes in some Partially Yes in some No No — Seychelles No Pharmacy Fully No No — No — No — No — Yes in some Fully Sierra Leone No Not available — No No — No — No — No — No — South Africa No Pharmacy No Yes No — No — No — Yes in most No Yes in some Fully South Sudan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Togo No Not available — No No — No — No — No — No — Uganda No Pharmacy No No No — No — No — No — Yes in most No United Republic of Tanzania No Not available — No No — No — No — Yes in some No No — Zambia No Pharmacy with Rx Partially No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Zimbabwe No Pharmacy with Rx No No No — No — Yes in some Partially No — Yes in some . . . Table 2.1.1 Support for treatment of tobacco dependence in Africa § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 160 161WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Antigua and Barbuda No Pharmacy No No No — No — Yes in some No No — No — Argentina Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially No — Bahamas No Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Barbados No Pharmacy No Yes No — No — Yes in some No Yes in some No Yes in some Fully Belize No Not available — No Yes in some Partially Yes in some No No — No — Yes in some Partially Bolivia (Plurinational State of) No Not available — No No — No — No — No — No — Brazil Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some No No — Canada Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in most Partially Yes in some No Yes in some Partially Chile Yes Pharmacy No No No — No — No — No — Yes in some No Colombia No Pharmacy Partially No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some No Costa Rica No Pharmacy Fully No Yes in some Fully Yes in most Fully Yes in some Fully Yes in some Fully Yes in some Partially Cuba Yes Not available — No Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Dominica No Not available — No No — No — No — No — No — Dominican Republic No Pharmacy No No No — No — Yes in most No No — Yes in some No Ecuador Yes Not available — No Yes in some Fully Yes in some Fully Yes in some Fully No — No — El Salvador Yes Pharmacy with Rx Fully No No — No — No — No — Yes in some Fully Grenada No Not available — No Yes in some Partially No — Yes in some No No — No — Guatemala No Pharmacy No No No — Yes in some Partially Yes in some No No — Yes in some No Guyana No . . . No Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Haiti No Not available — No No — No — No — No — No — Honduras Yes Not available — No Yes in some Fully Yes in some Partially Yes in some Partially No — Yes in some Partially Jamaica Yes Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially Yes in some No Yes in some Partially Mexico Yes Pharmacy Partially Yes Yes in most Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Nicaragua No Pharmacy No Yes No — No — No — No — No — Panama No Pharmacy Fully Yes Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Paraguay No Not available — Yes No — Yes in some Fully Yes in some Fully No — Yes in some Partially Peru Yes Pharmacy with Rx No No No — Yes in some Fully No — No — No — Saint Kitts and Nevis No Pharmacy No No No — No — No — No — No — Saint Lucia No . . . No No No — No — No — No — Yes in some Partially Saint Vincent and the Grenadines No Not available — No No — No — No — Yes in some . . . No — Suriname No Pharmacy No Yes Yes in most Fully No — No — Yes in some No Yes in some No Trinidad and Tobago No Pharmacy Fully Yes Yes in some Fully Yes in some Partially Yes in some No No — No — United States of America Yes General store Partially No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially No — Uruguay No Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in some Fully Yes in some No Yes in some Fully Venezuela (Bolivarian Republic of) No Pharmacy Fully No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Table 2.1.2 Support for treatment of tobacco dependence in the Americas § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 162 163WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Bangladesh No Not available — No Yes in some No Yes in some No No — Yes in some No No — Bhutan Yes Not available — . . . Yes in most Partially Yes in some Partially No — No — Yes in some No Democratic People's Republic of Korea No . . . Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Partially Yes in most Fully India Yes General store Fully No Yes in some Fully Yes in some Fully Yes in some . . . Yes in some . . . Yes in some Fully Indonesia Yes Pharmacy No No Yes in some Fully Yes in some Fully Yes in some No Yes in some No No — Maldives No Pharmacy with Rx Fully Yes Yes in most Fully Yes in most Fully Yes in some Partially No — Yes in some Fully Myanmar No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No No — Nepal No Not available — No Yes in some No Yes in some Fully No — No — No — Sri Lanka Yes Not available — No No — No — Yes in most Fully Yes in some Partially Yes in some Partially Thailand Yes Pharmacy No No Yes in most Fully Yes in most Fully Yes in some Fully Yes in most Partially Yes in some Fully Timor-Leste Yes Not available — Yes Yes in some Partially Yes in some Partially Yes in some Fully No — No — Table 2.1.3 Support for treatment of tobacco dependence in South-East Asia § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. South-East Asia SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 164 165WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Europe COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Albania No Not available — No Yes in some Fully No — No — No — No — Andorra No Pharmacy No No No — Yes in some Partially Yes in some Partially . . . . . . . . . . . . Armenia No Pharmacy No No Yes in some Fully No — No — . . . . . . No — Austria Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Azerbaijan Yes Not available — No No — No — No — No — Yes in some No Belarus Yes Pharmacy No No Yes in most Partially Yes in most Partially Yes in some Partially No — No — Belgium Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Bosnia and Herzegovina No Pharmacy No No Yes in most Fully No — No — No — Yes in some No Bulgaria Yes Pharmacy No Yes Yes in some Partially No — Yes in some No Yes in some Partially Yes in some Fully Croatia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some No Yes in some Partially Cyprus No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — Yes in some Fully Czechia Yes Pharmacy Partially — Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Denmark Yes Pharmacy Partially . . . Yes in some No No — No — Yes in most Fully Yes in some Fully Estonia Yes Pharmacy No No Yes in some Fully Yes in some Fully No — No — Yes in some Fully Finland Yes General store No No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some . . . Yes in some Partially France No Pharmacy Partially No Yes in some Partially Yes in most Partially Yes in some Partially . . . . . . Yes in some Partially Georgia Yes Pharmacy No — Yes in some Partially No — No — No — No — Germany Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Greece No Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially No — Yes in some Partially Hungary Yes Pharmacy No No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some . . . Yes in some Partially Iceland Yes General store No Yes No — No — No — Yes in some . . . No — Ireland Yes General store Partially Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Israel No Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Fully Italy Yes Pharmacy No No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Kazakhstan No Pharmacy No No Yes in some Fully No — Yes in some No Yes in some No Yes in some No Kyrgyzstan Yes Not available — No Yes in most Partially No — Yes in most Partially Yes in some No Yes in some Partially Latvia Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Lithuania No Pharmacy No Yes Yes in some Fully No — No — . . . . . . Yes in some No Luxembourg Yes Pharmacy Partially Yes Yes in some Partially Yes in some Partially Yes in some Partially . . . . . . Yes in some Partially Malta Yes Pharmacy No No Yes in some Fully Yes in some Fully No — Yes in some Fully No — Monaco No Pharmacy Fully . . . . . . . . . Yes in most Partially Yes in most Partially . . . . . . . . . . . . Montenegro No Not available — No No — No — No — No — No — Netherlands Yes Pharmacy Fully Yes Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Partially Yes in some Partially North Macedonia No Pharmacy No No No — Yes in some Fully Yes in some Fully No — Yes in some Fully Norway No General store No No Yes in some Partially Yes in some Fully Yes in some Fully Yes in some No Yes in some Partially Poland Yes Pharmacy No No Yes in some Partially No — Yes in some Partially Yes in some No Yes in some Partially Portugal No Not available — No Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Republic of Moldova Yes Not available — No Yes in some Fully No — No — . . . . . . Yes in some Partially Romania Yes Pharmacy No No Yes in some No Yes in some No Yes in some Partially Yes in some No Yes in some Partially Russian Federation Yes Not available — Yes Yes in some Fully No — No — No — No — San Marino No Not available — No No — No — No — . . . . . . No — Serbia No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully No — Yes in some Partially Slovakia Yes Pharmacy Partially No No — No — Yes in some Partially No — Yes in some Fully Slovenia Yes Pharmacy No Yes Yes in some Fully No — No — Yes in some Partially Yes in some Fully Spain No Pharmacy No No Yes in some Fully Yes in some Fully Yes in some Fully Yes in some Partially Yes in some Partially Sweden Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially Switzerland Yes Pharmacy No No Yes in some Partially Yes in some No Yes in most Partially Yes in some No . . . . . . Tajikistan No Not available — Yes No — No — No — . . . . . . No — Turkey Yes Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Partially Yes in some Partially Turkmenistan Yes Pharmacy No Yes Yes in most Fully Yes in some Fully Yes in most Fully No — Yes in some Fully Ukraine Yes Pharmacy No No Yes in some No No — No — No — No — United Kingdom of Great Britain and Northern Ireland No General store Partially . . . Yes in most Fully Yes in most Fully Yes in most Fully Yes in most Fully Yes in some Fully Uzbekistan No Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.4 Support for treatment of tobacco dependence in Europe § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 166 167WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Eastern Mediterranean COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Afghanistan No Pharmacy No No Yes in some No No — No — No — No — Bahrain No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — No — No — Djibouti No Not available — No No — No — No — No — No — Egypt Yes Not available — No No — No — No — No — Yes in some Partially Iran (Islamic Republic of) Yes Pharmacy No Yes Yes in some Partially Yes in some Partially Yes in some No Yes in some No Yes in some No Iraq No Pharmacy Partially Yes Yes in some Partially No — No — No — No — Jordan No Pharmacy Fully No Yes in some Fully Yes in some Partially Yes in some Partially Yes in some Partially Yes in some Partially Kuwait Yes Pharmacy Fully Yes Yes in some Fully No — No — Yes in most Partially Yes in some Fully Lebanon No Not available — No Yes in some Partially No — No — Yes in some Partially No — Libya No Not available — No Yes in some Partially No — No — No — Yes in some Partially Morocco No Pharmacy with Rx No No Yes in most No Yes in some No Yes in some No No — No — Oman No Pharmacy No No No — No — No — No — No — Pakistan No . . . No No No — No — No — Yes in some Partially Yes in some Partially Qatar No Pharmacy with Rx Fully Yes Yes in some Fully Yes in some Fully Yes in some . . . No — Yes in some Partially Saudi Arabia Yes Pharmacy Fully Yes Yes in most Fully Yes in some Fully No — Yes in most No Yes in some Fully Somalia No Not available — No No — No — No — No — No — Sudan No Not available — No Yes in some No No — No — No — No — Syrian Arab Republic No Not available — No Yes in most Partially Yes in most Partially Yes in most Partially No — No — Tunisia No Pharmacy with Rx Fully No Yes in most Partially Yes in most Partially Yes in some Partially No — Yes in some Partially United Arab Emirates Yes Pharmacy Partially . . . Yes in some Partially No — Yes in some . . . Yes in some Partially Yes in some Fully West Bank and Gaza Strip < No Pharmacy No No Yes in some No Yes in some No Yes in some No Yes in some No Yes in some No Yemen No Not available — No No — No — No — Yes in some No No — Table 2.1.5 Support for treatment of tobacco dependence in the Eastern Mediterranean § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 168 169WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Western Pacific COUNTRy NATIONAL TOLL-FREE qUIT LINE NICOTINE REPLACEMENT THERAPy PLACE AvAILABLE§ COST-COvERED INCLUDED IN ESSENTIAL MEDICINES LIST AvAILABLE* COST-COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED AvAILABLE* COST- COvERED Australia Yes General store Partially Yes Yes in most Partially Yes in most Partially Yes in most Partially Yes in some . . . Yes in some Partially Brunei Darussalam No Pharmacy Fully Yes Yes in some Fully Yes in some Fully No — Yes in some Fully No — Cambodia No Not available — No No — No — No — Yes in some No No — China No Not available — No Yes in some Partially Yes in some Partially Yes in some Partially Yes in some No Yes in some Partially Cook Islands No Pharmacy Fully No Yes in most Fully Yes in most Fully No — Yes in most Partially No — Fiji No Pharmacy No No Yes in some Fully Yes in some Fully No — No — No — Japan No Pharmacy Partially Yes Yes in some Partially Yes in some Partially No — Yes in some Partially No — Kiribati No Not available — No Yes in most Fully Yes in some Fully No — No — No — Lao People's Democratic Republic No Not available — No No — No — No — No — No — Malaysia No Pharmacy Fully Yes Yes in some Fully Yes in some Fully Yes in some Fully Yes in some No No — Marshall Islands No Pharmacy Partially Yes No — No — No — No — No — Micronesia (Federated States of) Yes . . . No No Yes in most Fully No — Yes in some Fully Yes in some No Yes in some No Mongolia No Pharmacy Partially Yes Yes in some Partially Yes in some No No — No — No — Nauru No Not available — No No — Yes in some No No — No — No — New Zealand Yes General store Fully Yes Yes in most Partially Yes in most Fully Yes in most Partially Yes in most Partially Yes in some Fully Niue No Pharmacy Fully No No — No — No — No — No — Palau No General store Partially No Yes in some Fully Yes in some Fully No — No — No — Papua New Guinea No Pharmacy No No No — No — No — No — No — Philippines No Pharmacy with Rx No Yes Yes in some Partially Yes in some Partially Yes in some No No — Yes in some Fully Republic of Korea Yes Pharmacy Partially No Yes in some Fully Yes in some Fully Yes in some Fully . . . . . . Yes in most Fully Samoa No Pharmacy No No No — No — No — Yes in some Fully No — Singapore Yes Pharmacy Partially No Yes in most Partially Yes in most Partially Yes in some Partially Yes in some Partially Yes in some Partially Solomon Islands No . . . No No Yes in some Fully No — No — No — No — Tonga Yes Pharmacy No No Yes in most Fully Yes in some Fully No — No — No — Tuvalu No Not available — No No — No — No — Yes in some No No — Vanuatu No Pharmacy No Yes No — No — No — No — No — Viet Nam Yes Pharmacy No No Yes in some Partially Yes in some Partially No — No — No — Table 2.1.6 Support for treatment of tobacco dependence in the Western Pacific § “Pharmacy with Rx” means that a prescription is required. * “Most” means in more than half. “Some” means in less than half. “No” means in none at all. . . . Data not reported/not available. — Data not required/not applicable. SMOKING CESSATION SUPPORT PRIMARy CARE FACILITIES HOSPITALS THE COMMUNITy OTHER SETTINGSOFFICES OF HEALTH PROFESSIONALS 170 171WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Africa Table 2.2.1 Tobacco cessation support, supplementary information in Africa COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Algeria Yes Yes Yes No No No Angola . . . . . . . . . . . . . . . . . . Benin No Yes Yes No No No Botswana No No Yes No No No Burkina Faso No No No No No No Burundi No No Yes No No No Cabo Verde No No Yes No No No Cameroon No No No No No No Central African Republic No No No No No Yes Chad No No No No No No Comoros No No No No No No Congo No No Yes No No No Côte d'Ivoire Yes Yes No No No No Democratic Republic of the Congo No No No No No No Equatorial Guinea . . . . . . . . . . . . . . . . . . Eritrea No No Yes No No No Eswatini No No No No No No Ethiopia Yes Yes Yes No No No Gabon No No No No No No Gambia No Yes Yes No No No Ghana Yes Yes Yes No No No Guinea No Yes Yes No No No Guinea-Bissau No No No No No No Kenya Yes Yes No Yes No No Lesotho No No No No No No Liberia No No No No No No Madagascar No Yes Yes No No No Malawi No No No No No No Mali No No Yes No No No Mauritania No No No No No No Mauritius Yes No Yes No No No Mozambique No No No No No No Namibia Yes No Yes No No No Niger No No No No No No Nigeria No No No Yes No No Rwanda No No Yes No No No Sao Tome and Principe No No No No No No Senegal No No Yes No No No Seychelles No No Yes Yes No No Sierra Leone No No No No No No South Africa . . . . . . . . . . . . . . . . . . South Sudan No No No No No No Togo Yes Yes Yes No No No Uganda No Yes Yes No No No United Republic of Tanzania No No No No No No Zambia No No No No No No Zimbabwe No No Yes No No No . . . Data not reported/not available. 172 173WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 The Americas Table 2.2.2 Tobacco cessation support, supplementary information in the Americas . . . Data not reported/not available. COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Antigua and Barbuda No No Yes No No No Argentina No Yes Yes No Yes Yes Bahamas . . . . . . . . . . . . . . . . . . Barbados No No Yes No No No Belize No No Yes No No No Bolivia (Plurinational State of) No No No No No No Brazil Yes Yes Yes No Yes No Canada No Yes Yes No Yes Yes Chile No Yes Yes No No Yes Colombia Yes No Yes No No Yes Costa Rica No Yes Yes Yes No Yes Cuba Yes Yes Yes Yes No Yes Dominica No No Yes No No No Dominican Republic No No Yes No No No Ecuador No Yes Yes No Yes Yes El Salvador No No Yes No No No Grenada No No Yes No No No Guatemala No Yes Yes No No No Guyana No Yes Yes No No No Haiti No No No No No No Honduras Yes Yes Yes Yes No No Jamaica No Yes Yes No No No Mexico Yes Yes Yes Yes Yes No Nicaragua No No Yes No No No Panama Yes Yes Yes Yes No No Paraguay No No Yes No No No Peru No No Yes No No No Saint Kitts and Nevis No No Yes No No No Saint Lucia No No Yes No No No Saint Vincent and the Grenadines No No No No No No Suriname No No Yes No No No Trinidad and Tobago Yes No Yes No No No United States of America Yes Yes Yes No Yes Yes Uruguay Yes Yes Yes Yes No Yes Venezuela (Bolivarian Republic of) Yes No No No No No 174 175WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.3 Tobacco cessation support, supplementary information in South-East Asia South-East Asia COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Bangladesh No No Yes No No No Bhutan No Yes Yes Yes No No Democratic People's Republic of Korea No Yes Yes No No No India Yes Yes Yes No Yes Yes Indonesia Yes Yes Yes No Yes Yes Maldives No Yes No No No No Myanmar Yes No No Yes No Yes Nepal No No No No No No Sri Lanka Yes No Yes No Yes No Thailand Yes Yes Yes Yes Yes Yes Timor-Leste No No No No No No 176 177WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. Europe Table 2.2.4 Tobacco cessation support, supplementary information in Europe COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Albania No No Yes No No No Andorra No No Yes No No No Armenia Yes Yes Yes No No No Austria No No Yes No Yes Yes Azerbaijan No Yes Yes Yes No No Belarus No Yes Yes No Yes No Belgium Yes Yes Yes No No Yes Bosnia and Herzegovina . . . . . . . . . . . . . . . . . . Bulgaria Yes Yes Yes Yes No Yes Croatia No Yes Yes Yes Yes No Cyprus Yes Yes Yes No No Yes Czechia No Yes Yes Yes Yes No Denmark No Yes Yes No Yes No Estonia Yes Yes Yes Yes No No Finland No Yes Yes No No No France Yes Yes Yes Yes No Yes Georgia Yes Yes Yes Yes Yes Yes Germany No Yes Yes No Yes Yes Greece Yes No Yes No No Yes Hungary No Yes No Yes Yes Yes Iceland No No No No Yes Yes Ireland Yes No Yes No Yes Yes Israel . . . . . . . . . . . . . . . . . . Italy Yes Yes Yes No Yes No Kazakhstan Yes Yes Yes Yes No No Kyrgyzstan No Yes Yes No Yes No Latvia Yes No Yes Yes Yes No Lithuania No No Yes No No Yes Luxembourg Yes Yes Yes No Yes No Malta No No No No Yes Yes Monaco No No No No No No Montenegro No No Yes No No No Netherlands Yes Yes Yes No Yes Yes North Macedonia No No Yes Yes No No Norway Yes Yes Yes No No No Poland Yes No Yes No Yes Yes Portugal Yes Yes Yes No No No Republic of Moldova Yes No Yes Yes Yes No Romania No No Yes No Yes Yes Russian Federation No Yes Yes Yes Yes Yes San Marino Yes No Yes No Yes No Serbia No No Yes No No No Slovakia Yes Yes No No Yes No Slovenia Yes No No Yes Yes Yes Spain Yes Yes Yes No No Yes Sweden Yes Yes Yes No Yes Yes Switzerland Yes Yes Yes No Yes Yes Tajikistan No Yes Yes Yes No No Turkey Yes Yes Yes No Yes No Turkmenistan No Yes Yes No Yes No Ukraine No Yes Yes No No No United Kingdom of Great Britain and Northern Ireland Yes Yes Yes Yes No Yes Uzbekistan No No Yes No No Yes 178 179WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 . . . Data not reported/not available. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Eastern Mediterranean Table 2.2.5 Tobacco cessation support, supplementary information in the Eastern Mediterranean COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Afghanistan Yes No No No No No Bahrain Yes Yes Yes No No Yes Djibouti . . . . . . . . . . . . . . . . . . Egypt No Yes Yes No Yes No Iran (Islamic Republic of) Yes Yes No Yes No Yes Iraq Yes Yes Yes Yes No No Jordan Yes No No No No No Kuwait Yes Yes Yes Yes No No Lebanon Yes No Yes No No No Libya No No No No No No Morocco Yes Yes Yes No No No Oman Yes No Yes No No No Pakistan No No No No No No Qatar No Yes Yes No No Yes Saudi Arabia Yes Yes Yes Yes No No Somalia . . . . . . . . . . . . . . . . . . Sudan No No No No No No Syrian Arab Republic No No No No No Yes Tunisia Yes Yes No No No Yes United Arab Emirates Yes No Yes Yes Yes Yes West Bank and Gaza Strip < Yes No Yes No No No Yemen Yes No No No No No 180 181WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 2.2.6 Tobacco cessation support, supplementary information in the Western Pacific Western Pacific COUNTRy THE COUNTRy HAS A NATIONAL TOBACCO CESSATION STRATEGy THE COUNTRy HAS NATIONAL TOBACCO CESSATION CLINICAL GUIDELINES TOBACCO CESSATION IS INCLUDED IN AT LEAST ONE NATIONAL DISEASE SPECIFIC TREATMENT GUIDELINE TOBACCO USE STATUS OF PATIENTS IS ROUTINELy RECORDED ON MEDICAL RECORDS NATIONAL TOLL-FREE qUIT LINES ARE INCLUDED ON HEALTH WARNINGS OR MASS MEDIA CAMPAIGNS TRAINING IN TOBACCO CESSATION IS INCLUDED IN HEALTH CARE DEGREE CURRICULA OR PRIMARy CARE PROvIDERS ARE REGULARLy TRAINED IN BRIEF TOBACCO INTERvENTIONS Australia Yes Yes Yes Yes Yes Yes Brunei Darussalam No Yes Yes No No No Cambodia Yes No No No No No China Yes Yes Yes No No Yes Cook Islands Yes Yes Yes No No No Fiji No No Yes No No No Japan No No No No No Yes Kiribati No No Yes No No No Lao People's Democratic Republic No No Yes No No No Malaysia Yes Yes Yes No No No Marshall Islands No No Yes No No No Micronesia (Federated States of) No No Yes No No No Mongolia No No Yes No No No Nauru No No No No No No New Zealand No Yes Yes Yes Yes Yes Niue No No No No No No Palau No No Yes No No No Papua New Guinea Yes No Yes No No No Philippines Yes Yes Yes No No No Republic of Korea Yes No Yes No Yes Yes Samoa No No No No No No Singapore Yes Yes Yes No Yes No Solomon Islands No No Yes No No No Tonga No No Yes No Yes Yes Tuvalu No No Yes No No No Vanuatu Yes No Yes No No No Viet Nam No Yes Yes Yes Yes No 182 183WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix III provides information on the year in which respective countries attained the highest level of achievement for five of the MPOWER measures. Data are shown separately for each WHO region. For Monitoring tobacco use the earliest year assessed is 2007. However, it is possible that while 2007 is reported as the year of highest achievement for some countries, they actually may have reached this level earlier. yEAR OF HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES Appendix iii: Years of highest level achievement of the MPOWER measure Raise taxes on tobacco are not included in this appendix. The share of taxes in product price depends both on tax policy and on demand and supply factors that affect manufacturing and retail prices. Countries with tax increases might have seen the share of tax remain unchanged or even decline if the non-tax share of price rose at the same, or a higher rate, complicating the interpretation of the year of highest level of achievement. See Technical Note III for details on the calculation of tax shares. 184 185WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. 8 Policy adopted but not implemented by 31 December 2018. Table 3.1 Year of highest level of achievement in selected tobacco control measures in Africa Africa COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Algeria Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 8 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire Democratic Republic of the Congo 2018 8 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia Gabon Gambia 2018 2018 Ghana 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2006 Nigeria 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe 186 187WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.2 Year of highest level of achievement in selected tobacco control measures in the Americas The Americas COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas 2018 Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2007* 2012 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2016 2011 Grenada Guatemala 2008 Guyana 2017 2018 8 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2013 2009 Nicaragua Panama 2012 2008 2005 2008 Paraguay Peru 2007* 2010 2011 Saint Kitts and Nevis Saint Lucia 2017 Saint Vincent and the Grenadines Suriname 2018 2013 2016 2013 Trinidad and Tobago 2009 2013 8 United States of America 2007* 2008 Uruguay 2007* 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 188 189WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.3 Year of highest level of achievement in selected tobacco control measures in South-East Asia South-East Asia COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Bangladesh 2014 2015 Bhutan 2014 Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar 2015 Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2007* 2010 2005 Timor-Leste 2018 190 191WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. Table 3.4 Year of highest level of achievement in selected tobacco control measures in Europe Europe COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2007* 2012 2016 Croatia 2007* 2017 Cyprus 2017 Czechia 2007* 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 France 2007* 2016 Georgia 2007* 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2007* 2016 Iceland 2007* Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2007* 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2007* 2016 Luxembourg 2007* 2016 2017 Malta 2007* 2010 2016 Monaco Montenegro Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2016 2016 Romania 2007* 2015 2016 Russian Federation 2007* 2013 2014 2013 San Marino Serbia 2007* Slovakia 2007* 2018 2016 Slovenia 2007* 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2018 Turkey 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan 192 193WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. < The term West Bank and Gaza Strip is used as a synonym to refer to the occupied Palestinian territory, including east Jerusalem. Table 3.5 Year of highest level of achievement in selected tobacco control measures in the Eastern Mediterranean Eastern Mediterranean COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2007* 2010 2008 Iran (Islamic Republic of) 2007* 2007 2008 2007 Iraq Jordan Kuwait 2007* 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco Oman Pakistan 2014 2009 2017 8 Qatar 2014 2016 Saudi Arabia 2018 2017 8 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 West Bank and Gaza Strip < 2011 Yemen 2013 194 195WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Note: an empty cell indicates that the population is not covered by the measure at the highest level of achievement. * Or earlier year. 8 Policy adopted but not implemented by 31 December 2018. Table 3.6 Year of highest level of achievement in selected tobacco control measures in the Western Pacific Western Pacific COUNTRy yEAR THE HIGHEST LEvEL OF ACHIEvEMENT WAS ATTAINED MONITOR TOBACCO USE 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 Australia 2007* 2005 2011 2004 Brunei Darussalam 2014 2012 2007 Cambodia 2014 2016 2016 China Cook Islands 2007* Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2007* 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 8 2018 8 Palau 2010 Papua New Guinea 2012 Philippines 2007* 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2007* 1999 2012 Solomon Islands 2013 Tonga Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013 196 197WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix IV provides information on whether the populations of the world’s 100 biggest cities are covered by selected tobacco control measures at the highest level of achievement. Cities are listed alphabetically. There are many ways to define geographically and measure the size of “a city”. For the purposes of this report, we focused on the jurisdictional boundaries of cities, since subnational laws will apply to populations within jurisdictions. Where a large “city” includes several jurisdictions or parts of jurisdictions, it is possible that not everyone in the entire “city” is covered by the same laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2016/ for the source data. HIGHEST lEvEl OF ACHIEvEMENT IN SElECTED TOBACCO CONTROl MEASURES IN THE 100 BIGGEST CITIES IN THE WORlD Appendix iV: A number of countries do not appear in Table 8 of the Demographic Yearbook because they did not report data. Countries missing from the list because they did not report data, but large enough to potentially qualify for the 100 biggest cities list are: Angola, Chad, Democratic Republic of the Congo, Nigeria, Sudan and Viet Nam. Refer to Technical Note I for definitions of highest level of achievement. 198 199WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world CITy * POPULATION (2016) COUNTRy 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 Abidjan 4 395 243 Côte d'Ivoire Adana 2 183 167 N N N N N Turkey Addis Ababa 2 979 086 N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 4 358 439 N N N Egypt Algiers 2 712 944 Algeria Amman 3 752 644 N N Jordan Ankara 5 270 575 N N N N N Turkey Antalya 2 288 456 N N N N N Turkey Baku 2 215 034 N N Azerbaijan Bandung 2 497 938 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N Thailand Beijing 19 610 000 N China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 520 031 N Germany Bogotá 7 980 001 N N N Colombia Brasília 2 977 216 N N N N N Brazil Brisbane 2 209 453 S N N N Australia Buenos Aires 13 879 707 N N N Argentina Bursa 2 842 547 N N N N N Turkey Busan 3 388 631 N Republic of Korea Cairo 7 248 671 N N N Egypt Cali 2 394 925 N N N Colombia Casablanca 3 352 399 Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 449 667 N Republic of Korea Damasus Rural 2 529 000 Syrian Arab Republic Dar es Salaam 4 364 541 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Fortaleza 2 609 716 N N N N N Brazil Giza 3 122 041 N N N Egypt Guadalajara 4 853 425 N N Mexico Guayaquil 2 531 371 N N Ecuador Hong Kong SAR 7 336 600 C C C China, Hong Kong SAR Houston 2 303 482 N United States of America Hyderabad 6 993 262 S N N India Incheon 2 914 455 N Republic of Korea Istanbul 14 657 434 N N N N N Turkey Izmir 4 168 415 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 374 235 N Indonesia Jiddah 3 430 697 N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 9 339 023 N N Pakistan Kiev 2 803 716 N Ukraine Kolkata 4 496 694 N N India Konya 2 130 544 N N N N N Turkey COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 200 201WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 4.1 Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world (continued) COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT City’s population covered by national legislation or policy at the highest level of achievement City’s population covered by state-level legislation or policy at the highest level of achievement City’s population covered by city-level legislation or policy at the highest level of achievement N S C CITy * POPULATION (2016) COUNTRy 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 Lahore 5 143 495 N N 8 Pakistan Lima 10 039 455 N N Peru London 8 135 667 N C N N United Kingdom of Great Brit- ain and Northern Ireland Los Angeles 3 976 322 S N United States of America Lucknow 2 817 105 N N India Madrid 3 186 241 N N N N Spain Mashhad 2 766 258 N N N Iran (Islamic Republic of) Medan 2 247 425 C Indonesia Medellín 2 486 723 N N N Colombia Melbourne 4 353 514 S N N N Australia Mexico City 21 497 029 S N N Mexico Monterrey 4 540 429 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Mwanza 2 772 509 United Republic of Tanzania Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 133 518 N Kenya New York 8 537 673 N United States of America Osaka 2 691 185 Japan Paris 2 243 833 N N N France Puebla-Tlaxcala 2 986 825 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N Philippines Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N Saudi Arabia Rome 2 867 672 N N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 561 252 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 834 687 N Republic of Korea Singapore 5 607 283 N N Singapore Surabaya 2 874 699 Indonesia Surat 4 501 610 N N India Sydney 4 526 479 N N N N Australia Tangerang 2 139 891 Indonesia Tashkent 2 393 176 Uzbekistan Tehran 8 154 051 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 225 286 S N N Mexico Toronto 2 876 095 N N N Canada Yangon 5 209 541 Myanmar Yaounde 2 873 567 N 8 Cameroon Yokohama 3 724 844 Japan COvERAGE AT THE HIGHEST LEvEL OF ACHIEvEMENT Notes: An empty cell indicates that the population in the respective city is not covered by the measure at the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement of the respective measure. * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Demographic Yearbook 2016 (available at: https://unstats.un.org/ unsd/demographic-social/products/dyb/documents/dyb2016/ table08.xls). 8 Policy adopted but not implemented by 31 December 2018. 202 203WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Appendix V shows the status of the WHO Framework Convention on Tobacco Control (WHO FCTC). Ratification is the international act by which countries that have already signed a convention formally state their consent to be bound by it. Accession is the international act by which countries that have not signed a treaty/convention formally state their consent to be bound by it. Acceptance and approval are the legal equivalent to ratification. Signature of a convention indicates that a country is not legally bound by the treaty but is committed not to undermine its provisions. STATUS OF THE WHO FRAMEWORK CONvENTION ON TOBACCO CONTROl Appendix V: The WHO FCTC entered into force on 27 February 2005. The treaty remains open for ratification, acceptance, approval, formal confirmation and accession indefinitely for States and eligible regional economic integration organizations wishing to become Parties to it. 204 205WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Afghanistan 29 June 2004 13 August 2010 Albania 29 June 2004 26 April 2006 Algeria 20 June 2003 30 June 2006 Andorra Angola 29 June 2004 20 September 2007 Antigua and Barbuda 28 June 2004 5 June 2006 Argentina 25 September 2003 Armenia 29 November 2004 a Australia 5 December 2003 27 October 2004 Austria 28 August 2003 15 September 2005 Azerbaijan 1 November 2005 a Bahamas 29 June 2004 3 November 2009 Bahrain 20 March 2007 a Bangladesh 16 June 2003 14 June 2004 Barbados 28 June 2004 3 November 2005 Belarus 17 June 2004 8 September 2005 Belgium 22 January 2004 1 November 2005 Belize 26 September 2003 15 December 2005 Benin 18 June 2004 3 November 2005 Bhutan 9 December 2003 23 August 2004 Bolivia (Plurinational State of) 27 February 2004 15 September 2005 Bosnia and Herzegovina 10 July 2009 a Botswana 16 June 2003 31 January 2005 Brazil 16 June 2003 3 November 2005 Brunei Darussalam 3 June 2004 3 June 2004 Bulgaria 22 December 2003 7 November 2005 Burkina Faso 22 December 2003 31 July 2006 Burundi 16 June 2003 22 November 2005 Cabo Verde 17 February 2004 4 October 2005 Cambodia 25 May 2004 15 November 2005 Cameroon 13 May 2004 3 February 2006 Canada 15 July 2003 26 November 2004 Central African Republic 29 December 2003 7 November 2005 Chad 22 June 2004 30 January 2006 Chile 25 September 2003 13 June 2005 China 10 November 2003 11 October 2005 Colombia 10 April 2008 a Comoros 27 February 2004 24 January 2006 Congo 23 March 2004 6 February 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 July 2003 21 August 2008 Côte d’Ivoire 24 July 2003 13 August 2010 Croatia 2 June 2004 14 July 2008 Cuba 29 June 2004 Cyprus 24 May 2004 26 October 2005 Czechia 16 June 2003 1 June 2012 Democratic People’s Republic of Korea 17 June 2003 27 April 2005 Democratic Republic of the Congo 28 June 2004 28 October 2005 Denmark 16 June 2003 16 December 2004 Djibouti 13 May 2004 31 July 2005 Dominica 29 June 2004 24 July 2006 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Dominican Republic Ecuador 22 March 2004 25 July 2006 Egypt 17 June 2003 25 February 2005 El Salvador 18 March 2004 21 July 2014 Equatorial Guinea 17 September 2005 a Eritrea Estonia 8 June 2004 27 July 2005 Eswatini 29 June 2004 13 January 2006 Ethiopia 25 February 2004 25 March 2014 European Union 16 June 2003 30 June 2005 c Fiji 3 October 2003 3 October 2003 Finland 16 June 2003 24 January 2005 France 16 June 2003 19 October 2004 AA Gabon 22 August 2003 20 February 2009 Gambia 16 June 2003 18 September 2007 Georgia 20 February 2004 14 February 2006 Germany 24 October 2003 16 December 2004 Ghana 20 June 2003 29 November 2004 Greece 16 June 2003 27 January 2006 Grenada 29 June 2004 14 August 2007 Guatemala 25 September 2003 16 November 2005 Guinea 1 April 2004 7 November 2007 Guinea-Bissau 7 November 2008 a Guyana 15 September 2005 a Haiti 23 July 2003 Honduras 18 June 2004 16 February 2005 Hungary 16 June 2003 7 April 2004 Iceland 16 June 2003 14 June 2004 India 10 September 2003 5 February 2004 Indonesia Iran (Islamic Republic of) 16 June 2003 6 November 2005 Iraq 29 June 2004 17 March 2008 Ireland 16 September 2003 7 November 2005 Israel 20 June 2003 24 August 2005 Italy 16 June 2003 2 July 2008 Jamaica 24 September 2003 7 July 2005 Japan 9 March 2004 8 June 2004 A Jordan 28 May 2004 19 August 2004 Kazakhstan 21 June 2004 22 January 2007 Kenya 25 June 2004 25 June 2004 Kiribati 27 April 2004 15 September 2005 Kuwait 16 June 2003 12 May 2006 Kyrgyzstan 18 February 2004 25 May 2006 Lao People’s Democratic Republic 29 June 2004 6 September 2006 Latvia 10 May 2004 10 February 2005 Lebanon 4 March 2004 7 December 2005 Lesotho 23 June 2004 14 January 2005 Liberia 25 June 2004 15 September 2009 Libya 18 June 2004 7 June 2005 Lithuania 22 September 2003 16 December 2004 Luxembourg 16 June 2003 30 June 2005 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 206 207WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Table 5.1 Status of the WHO Framework Convention on Tobacco Control, as of 8 May 2019 (continued) Madagascar 24 September 2003 22 September 2004 Malawi Malaysia 23 September 2003 16 September 2005 Maldives 17 May 2004 20 May 2004 Mali 23 September 2003 19 October 2005 Malta 16 June 2003 24 September 2003 Marshall Islands 16 June 2003 8 December 2004 Mauritania 24 June 2004 28 October 2005 Mauritius 17 June 2003 17 May 2004 Mexico 12 August 2003 28 May 2004 Micronesia (Federated States of) 28 June 2004 18 March 2005 Monaco Mongolia 16 June 2003 27 January 2004 Montenegro 23 October 2006 d Morocco 16 April 2004 Mozambique 18 June 2003 14 July 2017 Myanmar 23 October 2003 21 April 2004 Namibia 29 January 2004 7 November 2005 Nauru 29 June 2004 a Nepal 3 December 2003 7 November 2006 Netherlands 16 June 2003 27 January 2005 A New Zealand 16 June 2003 27 January 2004 Nicaragua 7 June 2004 9 April 2008 Niger 28 June 2004 25 August 2005 Nigeria 28 June 2004 20 October 2005 Niue 18 June 2004 3 June 2005 North Macedonia 30 June 2006 a Norway 16 June 2003 16 June 2003 AA Oman 9 March 2005 a Pakistan 18 May 2004 3 November 2004 Palau 16 June 2003 12 February 2004 Panama 26 September 2003 16 August 2004 Papua New Guinea 22 June 2004 25 May 2006 Paraguay 16 June 2003 26 September 2006 Peru 21 April 2004 30 November 2004 Philippines 23 September 2003 6 June 2005 Poland 14 June 2004 15 September 2006 Portugal 9 January 2004 8 November 2005 AA Qatar 17 June 2003 23 July 2004 Republic of Korea 21 July 2003 16 May 2005 Republic of Moldova 29 June 2004 3 February 2009 Romania 25 June 2004 27 January 2006 Russian Federation 3 June 2008 a Rwanda 2 June 2004 19 October 2005 Saint Kitts and Nevis 29 June 2004 21 June 2011 Saint Lucia 29 June 2004 7 November 2005 Saint Vincent and the Grenadines 14 June 2004 29 October 2010 Samoa 25 September 2003 3 November 2005 San Marino 26 September 2003 7 July 2004 Sao Tome and Principe 18 June 2004 12 April 2006 Saudi Arabia 24 June 2004 9 May 2005 COUNTRy DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EqUIvALENT) Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&lang=en, accessed 8 May 2019). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&lang=en Senegal 19 June 2003 27 January 2005 Serbia 28 June 2004 8 February 2006 Seychelles 11 September 2003 12 November 2003 Sierra Leone 22 May 2009 a Singapore 29 December 2003 14 May 2004 Slovakia 19 December 2003 4 May 2004 Slovenia 25 September 2003 15 March 2005 Solomon Islands 18 June 2004 10 August 2004 Somalia South Africa 16 June 2003 19 April 2005 South Sudan Spain 16 June 2003 11 January 2005 Sri Lanka 23 September 2003 11 November 2003 Sudan 10 June 2004 31 October 2005 Suriname 24 June 2004 16 December 2008 Sweden 16 June 2003 7 July 2005 Switzerland 25 June 2004 Syrian Arab Republic 11 July 2003 22 November 2004 Tajikistan 21 June 2013 a Thailand 20 June 2003 8 November 2004 Timor-Leste 25 May 2004 22 December 2004 Togo 12 May 2004 15 November 2005 Tonga 25 September 2003 8 April 2005 Trinidad and Tobago 27 August 2003 19 August 2004 Tunisia 22 August 2003 7 June 2010 Turkey 28 April 2004 31 December 2004 Turkmenistan 13 May 2011 a Tuvalu 10 June 2004 26 September 2005 Uganda 5 March 2004 20 June 2007 Ukraine 25 June 2004 6 June 2006 United Arab Emirates 24 June 2004 7 November 2005 United Kingdom of Great Britain and Northern Ireland 16 June 2003 16 December 2004 United Republic of Tanzania 27 January 2004 30 April 2007 United States of America 10 May 2004 Uruguay 19 June 2003 9 September 2004 Uzbekistan 15 May 2012 a Vanuatu 22 April 2004 16 September 2005 Venezuela (Bolivarian Republic of) 22 September 2003 27 June 2006 Viet Nam 3 September 2003 17 December 2004 Yemen 20 June 2003 22 February 2007 Zambia 23 May 2008 a Zimbabwe 4 December 2014 a * Ratification is the international act by which countries that have already signed a treaty or convention formally state their consent to be bound by it. a Accession is the international act by which countries that have not signed a treaty/ convention formally state their consent to be bound by it. A Acceptance is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention formally state their consent to be bound by it. c Formal confirmation is the international act corresponding to ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic integration organizations) formally state their consent to be bound by a treaty/ convention. d Succession is the international act, however phrased or named, by which successor States formally state their consent to be bound by treaties/ conventions originally entered into by their predecessor State. 208 209WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 World Health Organization Framework Convention on Tobacco Control Secretariat for their contributions to several chapters of this report, as well as for their overall comments on the draft. Hebe Naomi Gouda coordinated the production of this report with support from Kerstin Schotte, and with the help of Alexandra Choi and Pirathap Loganathan. Administrative support was provided by: Amal Amoune-Naal, Miriamjoy Aryee-Quansah, Gareth Burns, Rosane De Barros Serrao, Luis Madge, Zahra Ali Piazza, Ochid Romzi, Florence Taylor and Elizabeth Tecson. Priyanka Dahiya and Marine Perraudin were responsible for the country legislation assessment and analysis with support from Kritika Khanijo, Rebecca Röttger and Anastasia Vernikou. Data management, data analysis and creation of tables, graphs and appendices were performed by Alison Commar, with support from Soothesuk Kusumpa and Elza Anna Barzdina. The prevalence estimates were calculated by Alison Commar, with the collaboration of Ver Bilano and Edouard Tursan d’Espaignet. Data on tobacco cessation were updated by Dongbo Fu with support from Bowei Huang, Merideth Lewis-Cooney, Alexandra Choi and Tuba Asvar. The “Offering help to quit tobacco use” chapter was prepared with invaluable input from Heba Ayoub, Annette M David, Madmoud M Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, Min Kyung Lim, Tim McAfee, Pratima Murthy, Yvonne Olando, Jennifer Percival, Olivier Randriamahazosoa, Martin Raw, Galina Saharova, Etta Short, Ken Wassum, Dan Xiao, Jintana Yunibhand. We also thank Katherine Deland for preparing the chapter ‘WHO Framework Convention on Tobacco Control and the Protocol to Eliminate Illicit Trade in Tobacco Products’. Other aspects of report were greatly enriched by inputs from Jorge Alday, Anna Gilmore, Maciej Goniewicz, Brian King, Gan Quan. Analysis of the economics of tobacco for this report, including tobacco taxation and prices, were provided by Anne-Marie Perucic and Robert Totanes with support from Mark Goodchild, Roberto Iglesias, Dora Nicolazzo and Alejandro Ramos. Tax and price data were collected with support from officials from ministries of finance and ministries of health, and by Luk Joossens and Konstantin Krasovsky. We thank Jennifer Ellis, Kelly Henning and Adrienne Pizatella of the Bloomberg Initiative to Reduce Tobacco Use for their collaboration. Our thanks also go to Florence Rusciano for providing the maps. Our thanks also go to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health, specifically Joanna Cohen and Kevin Welding. We would also like to thank Vital Strategies for their collaboration in collecting and reviewing the data on tobacco control mass media campaigns, specifically Therese Buendia, Christina Curell and Alexey Kotov, as well as: Luiza Amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, Vaishakhi Mallik, Irina Morozova, Sandra Mullin, Nandita Murukutla, Nguyen Nhung, Rebecca Perl, Ancha Rachfiansyah, Benjamin Gonzalez Rubio, Md. Nasir Uddin and Winnie Chen Yu. Special thanks also to the Campaign for Tobacco Free Kids, especially Maria Carmona, Kaitlin Donley and Monique Muggli for their constructive exchange of tobacco control information and legislation. Thanks also to Rob Cunningham from the Canadian Cancer Society for exchanging information on health warning labels. We thank the team from Alboum for the quality and speed with which we received the translations of legislation. Vinayak Prasad, Douglas Bettcher and Vera Luiza da Costa e Silva reviewed the full report and provided final comments. Special thanks are due to our editors Aubra Godwin and Angela Burton and our designer Jean-Claude Fattier for their efficiency in helping to get this report published on time. Production of this WHO document has been supported by a grant from Bloomberg Philanthropies. The contents of this document are the sole responsibility of WHO and should not be regarded as reflecting the position of Bloomberg Philanthropies. Acknowledgements The World Health Organization gratefully acknowledges the contributions made to this report by the following individuals: WHO African Region: Jean-Marie Dangou, Deowan Mohee, Nivo Ramanandraibe, Noureiny Tcha-Kondor. WHO Region of the Americas: Francisco Armada Perez, Adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, Rosa Sandoval. WHO South-East Asia Region: Jagdish Kaur, Syed Mahfuzul Huq, Tara Mona Kessaram, Arvind Rinkoo (Bangladesh), Kencho Wangdi (Bhutan), Atul Dahal, Hye Ran Ri (DPR Korea), Praveen Sinha, Fikru Tesfaye Tullu (India), Farrukh Qureshi (Indonesia), Dina Kania (Indonesia), Fathimath Hudha (Maldives), Myo Paing (Myanmar), Lonim Dixit, Md Khurshid Alam Hyder (Nepal), Suveendran Thirupathy (Sri Lanka), Sushera Bunluesin, Renu Garg (Thailand), Leoneto Pinto (Timor-Leste). WHO European Region: Angela Ciobanu, Elizaveta Lebedeva, Kristina Mauer-Stender. WHO Eastern Mediterranean Region: Raouf Alebshehy, Fatimah El-Awa, Heba Fouad, Miriam Gordon, Radwa el Wakil. WHO Western Pacific Region: Melanie Aldeon, Ramon de Guzman, Mina Kashiwabara, Kate Lannan, Hai-Rim Shin, Daravuth Yel (Cambodia), Kelvin Khow Chuan Heng, Jiani Sun (China), Ada Moadsiri, Semenson Ehpel, Eunyoung Ko (Federated States of Micronesia), Pushpanjali Padayachi (Fiji), Koorio Tetabea (Kiribati), Douangkeo Thochongliachi (Lao People’s Democratic Republic), Paul Soo, Narwant Kaur (Malaysia), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (Mongolia), Anna Maalsen (Papua New Guinea), Florante Trinidad (Philippines), Kolisi Viki (Samoa), Kirsten Frandsen (Solomon Islands), Yutaro Setoya (Tonga), Tsogzolmaa Bayandorj (Vanuatu), Lam Nguyen Tuan, Pham Thi Quynh Nga (Viet Nam). WHO Headquarters Geneva: Virginia Arnold, Ferranda Cotado, Melanie Cowan, Hicham El-Berri, Ranti Fayokun, Sarah Galbraith-Emami, Marta Guglielmetti, Per Hasvold, Benn McGrady, Jeremias Paul, Leanne Riley, Kate Robertson, Susannah Robinson, Stefan Savin, Ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. Special thanks to Kelvin Khow Chuan Heng and Vera Luiza da Costa e Silva from the 210 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2019 Photographs and illustrations © World Health Organization Page 20 – Photographer: Diego Rodriguez Page 26 – Photographer: Sergey Volkov Page 50 – Photographer: Sergey Volkov Page 113 – Photographer: Eduardo Soteras Jalil Page 156 – Photographer: Nursila Dewi Page 202 – Photographer: David Spitz Page 208 – Photographer: David Spitz © The World Bank Page 49 – Photographer Scott Wallace Page 61 – Photographer: Sarah Farhat Page 64 – Photographer: Andy Trambly Page 100 – Photographer: Tom Perry Page 118/119 – Photographer: Mohammad Al-Arief Page 182 – Photographer: Khasar Sandag © Photoshare Page 46 – Photographer: Kassia Meinholdt Page 53 – Photographer: Sanghamitra Sarkar Page 81 – David Alexander/Johns Hopkins Center for Communication Programs Page 90 – Photographer: Syed Ziaul Habib Roobon Page 126 – Photographer: Sumon Yusuf Page 142 – Samy Rakotoniaina / MSH Page 196 – Photographer: Meagan Harrison Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 30 – © WHO FCTC Convention Secretariat Page 34 – © Fondo Solidario para la Salud - FOSALUD, El Salvador Page 55 – © Photographer: Husain Akbar Page 57 – © Photographer: Husain Akbar Page 63 – © Ministry of Health, Brazil Page 74 – © Noncommunicable Diseases Unit at Federal Ministry of Health, Sudan Page 75 – © National Institute of Health and Research and Development, Indonesia Page 79 – © Photographer: Robert Totanes Page 80 – © Xi’an Health Commission, China Page 81 – © Mr Omar Badjie, Ministry of Health, Gambia Page 88 – © Ministry of Health and Family Welfare, India Page 88 – © Dr Oumar Ba, Ministry of Health and Social Action, Senegal Page 89 – © National Tobacco Control Center, The Republic of Korea Page 89 – © Ministry of Health, Ecuador Page 94 – © Committee of Healthcare and Social Issues, Parliament of Georgia Page 95 – © Ministry of Health, Uruguay Page 99 – © Young Guns Media, Myanmar Page 99 – © WHO Country Office China Page 104 – © Mrs Rosalie Likibi-Boho, Ministry of Health, Republic of Congo Page 104 – © Ada Moadsiri, World Health Organization Page 105 – © Stabroek News, Guyana Page 116 – © Department of Health, Ireland Page 117 – © Mrs Hanitra Ratsirison, Ministry of Health, Madagascar The WHO report on the global tobacco epidemic, 2019 was made possible by funding from Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco ISBN 978 92 4 151282 4

ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Предложение помощи в целях прекращения употребления табака живет и действует BПри правильной поддержке шансы отказаться от употребления табака могут увеличиться более чем в два раза. Отказ от употребления табака приносит людям немедленную и существенную пользу для здоровья. . Мы не достигнем глобальных целей по сокращению потребления табака и количества связанных с ним смертей, если не поможем людям бросить курить прямо сейчас. Доклад ВОЗ о глобальной табачной эпидемии, 2019 г.: предложение помощи в целях прекращения употребления табака — седьмой из серии докладов ВОЗ, в которых определяется состояние табачной эпидемии и оценивается эффективность мер, принимаемых с целью положить ей конец. Monitor Protect Offer Warn Enforce Raise Мониторинг употребления табака и стратегий профилактики Защита людей от табачного дыма Предложение помощи в целях прекращения употребления табака Предупреждение об опасностях, связанных с табаком Обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий Повышение налогов на табачные изделия Помощь людям в отказе от употребления табака дает больший эффект, когда направленные на это усилия сочетаются с другими стратегиями борьбы против табака. 8Доклад ВОЗ о глобальной табачной эпидемии, 2019 год: предложение помощи в целях прекращения употребления табака [WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use] ISBN 978-92-4-002954-5 (онлайн-версия) ISBN 978-92-4-002955-2 (версия для печати) © Всемирная организация здравоохранения, 2021 Некоторые права защищены. Настоящая публикация распространяется на условиях лицензии Creative Commons 3.0 IGO «С указанием авторства – Некоммерческая – Распространение на тех же условиях» (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/ igo/deed.ru). Лицензией допускается копирование, распространение и адаптация публикации в некоммерческих целях с указанием библиографической ссылки согласно нижеприведенному образцу. Никакое использование публикации не означает одобрения ВОЗ какой-либо организации, товара или услуги. Использование логотипа ВОЗ не допускается. Распространение адаптированных вариантов публикации допускается на условиях указанной или эквивалентной лицензии Creative Commons. При переводе публикации на другие языки приводятся библиографическая ссылка согласно нижеприведенному образцу и следующая оговорка: «Настоящий перевод не был выполнен Всемирной организацией здравоохранения (ВОЗ). ВОЗ не несет ответственности за содержание или точность перевода. Аутентичным подлинным текстом является оригинальное издание на английском языке». Урегулирование споров, связанных с условиями лицензии, производится в соответствии с согласительным регламентом Всемирной организации интеллектуальной собственности (http://www.wipo.int/amc/en/mediation/rules/). Образец библиографической ссылки: Доклад ВОЗ о глобальной табачной эпидемии, 2019 год: предложение помощи в целях прекращения употребления табака [WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use]. Женева: Всемирная организация здравоохранения; 2021. Лицензия: CC BY-NC-SA 3.0 IGO. Данные каталогизации перед публикацией (CIP). Данные CIP доступны по ссылке http://apps.who.int/iris. Приобретение, авторские права и лицензирование. По вопросам приобретения публикаций ВОЗ см. http://apps.who.int/ bookorders. По вопросам оформления заявок на коммерческое использование и направления запросов, касающихся права пользования и лицензирования, см. http://www.who.int/about/licensing. Материалы третьих сторон. Пользователь, желающий использовать в своих целях содержащиеся в настоящей публикации материалы, принадлежащие третьим сторонам, например таблицы, рисунки или изображения, должен установить, требуется ли для этого разрешение обладателя авторского права, и при необходимости получить такое разрешение. Ответственность за нарушение прав на содержащиеся в публикации материалы третьих сторон несет пользователь. Оговорки общего характера. Используемые в настоящей публикации обозначения и приводимые в ней материалы не означают выражения мнения ВОЗ относительно правового статуса любой страны, территории, города или района или их органов власти или относительно делимитации границ. Штрихпунктирные линии на картах обозначают приблизительные границы, которые могут быть не полностью согласованы. Упоминания определенных компаний или продукции определенных производителей не означают, что они одобрены или рекомендованы ВОЗ в отличие от других аналогичных компаний или продукции, не названных в тексте. Названия патентованных изделий, исключая ошибки и пропуски в тексте, выделяются начальными прописными буквами. ВОЗ приняты все разумные меры для проверки точности информации, содержащейся в настоящей публикации. Однако данные материалы публикуются без каких-либо прямых или косвенных гарантий. Ответственность за интерпретацию и использование материалов несет пользователь. ВОЗ не несет никакой ответственности за ущерб, связанный с использованием материалов. Министерство здравоохранения Российской Федерации финансировало перевод этой публикации на русский язык. Издание подготовлено при финансовом содействии Благотворительного фонда Bloomberg Philanthropies ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Предложение помощи в целях прекращения употребления табака СОДЕРЖАНИЕ 13 Обращение д-ра Тедроса Адханома Гебрейесуса, Генерального директора ВОЗ 15 Обращение г-на Майкла Блумберга, Глобального посла ВОЗ по борьбе с неинфекционными заболеваниями 17 Обращение д-ра Vera Luiza da Costa e Silva, руководителя Секретариата РКБТ ВОЗ 18 РЕЗЮМЕ 26 РАМОЧНАЯ КОНВЕНЦИЯ ВОЗ ПО БОРЬБЕ ПРОТИВ ТАБАКА И ПРОТОКОЛ О ЛИКВИДАЦИИ НЕЗАКОННОЙ ТОРГОВЛИ ТАБАЧНЫМИ ИЗДЕЛИЯМИ 34 ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА 50 ИЗДЕЛИЯ ИЗ НАГРЕВАЕМОГО ТАБАКА 54 ЭЛЕКТРОННЫЕ СИСТЕМЫ ДОСТАВКИ НИКОТИНА 58 ВМЕШАТЕЛЬСТВО ТАБАЧНОЙ ПРОМЫШЛЕННОСТИ: САМОЕ БОЛЬШОЕ ПРЕПЯТСТВИЕ НА ПУТИ СОКРАЩЕНИЯ ПОТРЕБЛЕНИЯ ТАБАКА 66 ЭФФЕКТИВНЫЕ МЕРЫ БОРЬБЫ ПРОТИВ ТАБАКА 68 Мониторинг употребления табака и стратегий профилактики 74 Защита людей от табачного дыма 80 Предложение помощи в целях прекращения употребления табака 88 Предупреждение об опасностях, связанных с табаком 94 Антитабачные кампании в средствах массовой информации 98 Обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий 104 Повышение налогов на табачные изделия 112 Национальные программы борьбы против табака: жизненно важные программы для прекращения табачной эпидемии 116 ЗАКЛЮЧЕНИЕ 118 БИБЛИОГРАФИЧЕСКИЕ ССЫЛКИ 126 ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ I: Оценка существующих мер политики и их соблюдения 134 ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ II: Распространенность употребления табака в государствах-членах ВОЗ 136 ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ III: Налоги на табачные изделия в государствах-членах ВОЗ 143 ПРИЛОЖЕНИЕ I: Сводные данные о применении мер MPOWER по регионам 157 ПРИЛОЖЕНИЕ II: Лечение табачной зависимости 183 ПРИЛОЖЕНИЕ III: Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака 197 ПРИЛОЖЕНИЕ IV: Наивысший уровень достижений в реализации отдельных мер борьбы против табака в 100 крупнейших городах мира 203 ПРИЛОЖЕНИЕ V: Статус Рамочной конвенции ВОЗ по борьбе против табака 209 ВЫРАЖЕНИЕ ПРИЗНАТЕЛЬНОСТИ ПРИЛОЖЕНИЕ VI: Данные о глобальных мерах борьбы против табака ПРИЛОЖЕНИЕ VII: Обзор положения дел в странах ПРИЛОЖЕНИЕ VIII: Доходы от налогов на табачные изделия ПРИЛОЖЕНИЕ IX: Налоги и цены на табачные изделия и их ценовая доступность ПРИЛОЖЕНИЕ X: Оценки распространенности курения, стандартизированные по возрасту, 2017 год ПРИЛОЖЕНИЕ XI: Представленные странами данные о распространенности курения ПРИЛОЖЕНИЕ XII: Картографическое представление данных о глобальных мерах борьбы против табака Приложения VI-XIII доступны в сети Интернет по адресу: http://www.who.int/tobacco/global_report/en 12 13ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД мероприятия по прекращению курения, проводимые на уровне всего населения. В то же время следует поощрять внедрение инноваций и в полном объеме использовать мобильные технологии для улучшения доступа к многочисленным и труднодоступным группам населения. Важность борьбы против табака и отказа от его употребления для здоровья людей во всем мире отражена в Целях в области устойчивого развития, которые призывают к более активному осуществлению РКБТ ВОЗ. Меры MPOWER могут помочь правительствам, предоставляя ключевые инструменты для борьбы с глобальной табачной эпидемией. Мы сможем достичь наших глобальных целей по сокращению распространенности употребления табака и предотвратить годы изнурительных болезней и миллионы смертей только в том случае, если поможем людям бросить курить прямо сейчас. Д-р Тедрос Адханом Гебрейесус Генеральный директор Всемирной организации здравоохранения В ПЕРИОД ПОСЛЕ 2007 ГОДА ЧИСЛО ЛЮДЕЙ, ЗАЩИЩЕННЫХ ХОТЯ БЫ ОДНОЙ МЕРОЙ MPOWER, УВЕЛИЧИЛОСЬ БОЛЕЕ ЧЕМ В ЧЕТЫРЕ РАЗА «Обеспечение доступа к эффективным мерам, направленным на прекращение курения, и поощрение их использования существенно повышает вероятность успешного отказа от употребления табака». Д-р Тедрос Адханом Гебрейесус, Генеральный директор ВОЗ «Борьба против табака является прекрасным примером того, чего можно достичь в области охраны здоровья людей во всем мире благодаря всеобщей приверженности этой борьбе». Борьба против табака является прекрасным примером того, чего можно достичь в области охраны здоровья людей во всем мире благодаря всеобщей приверженности этой борьбе. С момента принятия в 2003 году Рамочной конвенции ВОЗ по борьбе против табака (РКБТ ВОЗ) большинство стран добилось значительных успехов в реализации мер, направленных на эту борьбу. В 2008 году ВОЗ представила шесть мер MPOWER для оказания помощи странам в осуществлении РКБТ ВОЗ с использованием эффективных мероприятий, которые, вне всякого сомнения, снижают спрос на табачные изделия. С момента введения мер MPOWER количество стран, применивших хотя бы одну меру, соответствующую лучшим образцам мировой практики, увеличилось более чем в четыре раза. Теперь мы можем сообщить, что 136 стран с общим населением 5 миллиардов человек реализовали по крайней мере одну из ключевых практических мер политики по сокращению спроса на табачные изделия. Как никогда ранее, люди осознают вред и негативные последствия употребления табака. Отчасти благодаря этим успехам многие потребители табака теперь хотят бросить курить; и мы знаем, как им помочь. В данном седьмом Докладе ВОЗ о глобальной табачной эпидемии основное внимание уделяется мере MPOWER «О»: «Предложение помощи в целях прекращения употребления табака». Большинство будущих смертных случаев, связанных с табаком, будет наблюдаться среди его сегодняшних потребителей, что в непропорциональной мере повлияет на страны с низким и средним уровнями дохода. Обеспечение доступа к эффективным мерам, направленным на прекращение курения, и поощрение их использования существенно повышает вероятность успешного отказа от употребления табака. Статья 14 РКБТ ВОЗ призывает к предоставлению услуг, направленных на прекращение употребления табака, на страновом уровне. Рекомендуемые подходы включают в себя краткие консультации в учреждениях первичной медико-санитарной помощи, бесплатные национальные телефонные линии для бросающих курить, оплачиваемую государством никотинзаместительную терапию и использование цифровых и мобильных технологий для расширения возможностей тех, кто хочет бросить курить. Эти меры наиболее эффективны в случае их комплексного использования, но могут применяться и поэтапно, когда ресурсы страны ограничены. Помощь в отказе от употребления табака может и должна быть включена в любую стратегию всеобщего охвата услугами здравоохранения. За последнее десятилетие произошло резкое увеличение числа стран со средним уровнем дохода, которые включают услуги для бросающих курить с частичной или полной компенсацией затрат в некоторые или большинство своих услуг первичной медико- санитарной помощи — охват населения такими услугами вырос с 16% в 2007 году до 78% в 2018 году. Среди стран с высоким уровнем дохода этот показатель вырос с 61% до 97%. Однако внедрение полного пакета услуг по прекращению курения на уровне передовой практики остается удивительно редким явлением в большинстве стран. По состоянию на 2018 год только 23 страны (включая только шесть стран со средним уровнем дохода и одну страну с низким уровнем дохода) оказывали всестороннюю поддержку потребителям табака, обратившимся за помощью с целью отказаться от курения. Правительства должны признать эту неудовлетворенную потребность и действовать без промедления соответствующим образом в рамках всеобъемлющей стратегии борьбы против табака. Приоритетной задачей для стран должны стать экономически эффективные 14 15ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД сотрудничестве с Генеральным директором Тедросом Гебрейесусом и ВОЗ в целях борьбы с НИЗ, и глобальная поддержка эффективной политики неуклонно растет. Но борьба с агрессивной и постоянно развивающейся табачной промышленностью еще далека от завершения. Большее число стран могут уделять гораздо больше внимания проблеме употребления табака и предпринимать решительные действия по спасению человеческих жизней. И объединив усилия, направленные на внедрение проверенных стратегий во всех странах, мы можем спасти еще миллионы жизней. Майкл Р. Блумберг Глобальный посол ВОЗ по борьбе с неинфекционными заболеваниями и травмами Основатель Благотворительного фонда Bloomberg Philanthropies ПЯТЬ МИЛЛИАРДОВ ЧЕЛОВЕК В НАСТОЯЩЕЕ ВРЕМЯ ОХВАЧЕНЫ МЕРАМИ MPOWER, И ЭТО СВИДЕТЕЛЬСТВУЕТ О ТОМ, ЧТО СТРАНЫ МОГУТ ВЫИГРАТЬ БОРЬБУ С ТАБАЧНОЙ ЭПИДЕМИЕЙ «Объединив усилия, направленные на внедрение проверенных стратегий во всех странах, мы можем спасти еще миллионы жизней». Майкл Р. Блумберг, Глобальный посол ВОЗ по борьбе с неинфекционными заболеваниями Основатель Благотворительного фонда Bloomberg Philanthropies Употребление табака представляет огромную угрозу для общественного здоровья во всем мире, унося ежегодно более восьми миллионов человеческих жизней. Ради спасения этих жизней все большее число стран определяет борьбу против табака в качестве своей приоритетной задачи, но еще многое предстоит сделать. Всемирная организация здравоохранения и Благотворительный фонд Bloomberg Philanthropies стремятся ускорить темпы сокращения употребления табака во всем мире. Перед нами стоят непростые задачи, но вместе мы доказываем, что в этой борьбе можно победить. ВОЗ внимательно следит за реализацией шести мер MPOWER по сокращению употребления табака, и, демонстрируя их результат, мы помогаем побудить все большее число стран принять их на вооружение. Меры MPOWER в соответствии с Рамочной конвенцией ВОЗ по борьбе против табака помогли странам добиться беспрецедентного прогресса. С 2007 года доля населения мира, охваченного хотя бы одной мерой MPOWER, увеличилась более чем в четыре раза. В результате сегодня пять миллиардов человек защищены от пагубных последствий употребления табака, а число стран, в которых существует передовая практика отказа от курения, увеличилось более чем в два раза — с 10 до 23. В дополнение к консультациям работников служб первичной медико-санитарной помощи и бесплатным телефонным линиям для бросающих курить, цифровые технологии меняют способы доступа людей к услугам по прекращению курения и получения направленной на это помощи. В настоящем докладе освещаются глобальные усилия, направленные на то, чтобы помочь людям отказаться от употребления табака, и подробно описаны некоторые из наших наиболее важных достижений. В Индии, например, значительно расширился доступ к услугам для бросающих курить благодаря инновационной программе, которая позволяет ее участникам с помощью своих мобильных телефонов регистрироваться и получать индивидуальную поддержку при намерении бросить курить. А Бразилия теперь является второй страной в мире, которая реализовала все меры MPOWER на самом высоком уровне. Неинфекционные заболевания (НИЗ) являются причиной более двух третей смертных случаев в развивающихся странах, а употребление табака является основным фактором риска таких НИЗ, как рак и болезни сердца. Тем не менее, программы, направленные на сокращение числа случаев НИЗ, постоянно недофинансируются. На мероприятия по предупреждению НИЗ идет только 2% финансирования, выделяемого на цели развития. Благотворительный фонд Bloomberg Philanthropies работает в тесном «ВОЗ внимательно следит за реализацией шести мер MPOWER по сокращению употребления табака, и, демонстрируя их результат, мы помогаем побудить все большее число стран принять их на вооружение». 16 17ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД БОРЬБА ПРОТИВ ТАБАКА ЯВЛЯЕТСЯ КЛЮЧЕВОЙ СОСТАВЛЯЮЩЕЙ ЦЕЛЕЙ В ОБЛАСТИ УСТОЙЧИВОГО РАЗВИТИЯ, ЧТО ДЕЛАЕТ СКОРЕЙШЕЕ И ПОЛНОЕ ОСУЩЕСТВЛЕНИЕ РКБТ ВОЗ ВСЕ БОЛЕЕ НЕОТЛОЖНОЙ ЗАДАЧЕЙ, ЧЕМ КОГДА БЫ ТО НИ БЫЛО Д-р Vera Luiza da Costa e Silva Руководитель Секретариата РКБТ ВОЗ «Главной целью договора является защита нынешнего и будущих поколений от разрушительных последствий для здоровья людей, а также экономических, социальных и экологических последствий употребления табака». «Совершенно очевидно, что для достижения задач ЦУР, посвященных борьбе против табака, необходима мощная поддержка в прекращении его употребления». Д-р Vera Luiza da Costa e Silva, Руководитель секретариата РКБТ ВОЗ данные, позволяющие проанализировать прогресс в деле защиты населения земного шара от того, что в настоящее время является самой крупной предотвратимой причиной смерти людей во всем мире. Как показывает это последнее издание, нам есть чему выразить свое одобрение. Уже сейчас 5 миллиардов человек охвачены по крайней мере одной основной мерой РКБТ ВОЗ по сокращению спроса на табак, реализованной на самом высоком уровне. И 136 стран в настоящее время защищают свое население, осуществляя одну или несколько таких стратегий на уровне лучших образцов передовой практики (что зафиксировано в настоящем докладе). Однако, хотя некоторые Стороны добиваются устойчивого прогресса, многие еще отстают, и необходимо предпринять гораздо больше усилий. Ни для кого не секрет, что табачная промышленность является нашим главным препятствием на пути к прекращению табачной эпидемии. Эта отрасль промышленности получает огромные прибыли от продажи табачных изделий и формирования у людей табачной зависимости — и ее представители не хотят ничего менять. Но ради здоровья людей, на благо наших детей и будущих поколений все должно измениться. Мы глубоко обеспокоены тем фактом, что табачная эпидемия перемещается в развивающиеся страны, где менее обеспеченные ресурсами государства оказываются не в состоянии противостоять освоению табачной промышленностью новых рынков — зачастую путем вопиющего вмешательства в формирование политики общественного здравоохранения. Осуществление Статьи 5.3 РКБТ ВОЗ, которая требует от Сторон защищать политику общественного здравоохранения от табачной промышленности, является важным шагом на пути предотвращения вмешательства этой промышленности в процесс разработки политики общественного здравоохранения. В настоящем докладе основное внимание уделяется прекращению употребления табака и излагается достигнутый на сегодняшний день прогресс в осуществлении статьи 14 РКБТ ВОЗ. Сокращение спроса на табак путем оказания поддержки в отказе от его употребления является одной из основных стратегий РКБТ ВОЗ по сокращению спроса. Статья 14 РКБТ ВОЗ и руководящие принципы ее осуществления призывают Стороны принять ряд мер по оказанию помощи потребителям табака в отказе от курения. Когда страны осуществляют такие меры, они могут одновременно гарантировать, что эти мероприятия станут неотъемлемой частью всеобщего охвата услугами здравоохранения. В настоящем докладе также подчеркивается тот факт, что меры по прекращению употребления табака по-прежнему относятся Секретариат Рамочной конвенции ВОЗ по борьбе против табака (РКБТ ВОЗ) и Стороны Протокола о ликвидации незаконной торговли табачными изделиями приветствуют публикацию седьмого Доклада ВОЗ о глобальной табачной эпидемии. Сто восемьдесят одна Сторона РКБТ ВОЗ взяла на себя обязательство спасать жизни людей путем ведения борьбы против табака. Основываясь на убедительных фактических данных, РКБТ ВОЗ устанавливает минимальные стандарты, которыми Стороны могут руководствоваться при принятии жестких мер политики и законодательства для борьбы с табачной эпидемией, которая ежегодно становится причиной восьми миллионов смертей во всем мире. Главной целью договора является защита нынешнего и будущих поколений от разрушительных последствий для здоровья людей, а также экономических, социальных и экологических последствий употребления табака. В прошлом году мы стали свидетелями двух крупных достижений в борьбе против табака. Первым из них стало вступление в силу Протокола о ликвидации незаконной торговли табачными изделиями 25 сентября 2018 года. К июню 2019 года пятьдесят пять Сторон РКБТ ВОЗ уже присоединились к этому Протоколу, что свидетельствует об их растущей приверженности решению этой проблемы. Вторым крупным достижением стало принятие в октябре 2018 года Конференцией Сторон (КС, руководящим органом РКБТ ВОЗ) Глобальной стратегии по ускорению борьбы против табака: содействие устойчивому развитию путем осуществления РКБТ ВОЗ, 2019–2025 гг. Эта стратегия служит ориентиром для осуществления РКБТ ВОЗ в течение следующих семи лет, включая деятельность Сторон, Секретариата Конвенции и других заинтересованных сторон, и служит основой для планирования работы и составления бюджетов на следующие три двухгодичных периода. С момента вступления в силу в 2005 году, РКБТ ВОЗ использует полезную информацию из выходящего два раза в год Доклада о глобальном прогрессе в осуществлении Рамочной конвенции ВОЗ по борьбе против табака, в котором сообщается о реализации всех положений РКБТ ВОЗ. Этот доклад представляется на каждую сессию Конференции Сторон и публикуется Секретариатом Конвенции на своем веб- сайте. В последнем докладе, опубликованном в 2018 году, отмечается растущая приверженность Сторон осуществлению РКБТ ВОЗ. Доклад ВОЗ о глобальной табачной эпидемии, публикуемый каждые 2 года, начиная с 2008, предоставляет сопоставимые к числу наименее реализуемых из всех мер РКБТ ВОЗ по сокращению спроса на табачные изделия; и только в общей сложности 23 страны, большинство из которых являются странами с высоким уровнем дохода, предоставляют наиболее эффективные услуги по прекращению употребления табака. Очевидно, что есть возможности для более активных действий, и причина говорит сама за себя: если бы меры по прекращению курения были реализованы на самом высоком уровне в 14 странах в период с 2007 по 2014 год, можно было бы спасти 1,5 миллиона человеческих жизней. Секретариат Конвенции недавно документально зафиксировал успешные практические примеры осуществления Статьи 14 РКБТ ВОЗ в отношении сопутствующих заболеваний, когда употребление табака оказывает влияние на бремя болезней (например, меры в отношении туберкулеза и ВИЧ/СПИДа, а также неинфекционных заболеваний). Сегодня мы обладаем более чем десятилетним опытом и знаниями в области борьбы с употреблением табака. Наша роль в содействии устойчивому развитию в настоящее время признана в рамках повестки дня Целей в области устойчивого развития (ЦУР) на период до 2030 года, поскольку задача 3A призывает к наращиванию усилий в осуществлении РКБТ ВОЗ во всех странах. Совершенно очевидно, что для достижения задач ЦУР, посвященных борьбе против табака, необходима мощная поддержка в прекращении его употребления. Мы даем высокую оценку этому новому докладу за предоставление качественной информации и сопоставимых данных о прогрессе в реализации отдельных мер по сокращению спроса на табачные изделия. Отказ от употребления табака оказывает непосредственное влияние на состояние здоровья людей, а обеспечение того, чтобы эффективные услуги по прекращению курения были частью любой стратегии борьбы против табака, позволит максимально использовать потенциал этих услуг для спасения человеческих жизней. 18 19ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Резюме сложности 36 стран ввели одну или несколько мер MPOWER на самом высоком уровне достижений в их реализации. Отказ от употребления табака является вопросом, требующим особого внимания Предложение помощи в целях прекращения употребления табака — главная тема седьмого Доклада ВОЗ о глобальной табачной эпидемии — является важным компонентом любой стратегии борьбы против табака. Глобальные цели по сокращению употребления табака не будут достигнуты, если нынешние потребители табака не бросят курить, и действительно, многие из них говорят о своем желании отказаться от этой привычки. С помощью экономически эффективных мероприятий, проводимых на уровне всего населения, как предусмотрено мерой «O» стратегии MPOWER (Предложение помощи в целях прекращения употребления табака), шансы потребителей табака на успешный отказ от курения существенно повышаются. К сожалению, в период после 2007 года только 13 новых стран начали осуществлять всесторонние программы по прекращению употребления табака. В настоящее время эта мера применяется в 23 странах, по сравнению с 10 странами в 2007 году. Однако с точки зрения охвата населения прогресс все же обнадеживает. Одна треть населения мира — 2,4 миллиарда человек в 23 странах — имеет доступ к услугам по прекращению курения, предоставляемым на уровне передовой практики. Это на 2 миллиарда больше людей (26% населения мира), защищенных всесторонними программами поддержки в отказе от курения, по сравнению с 2007 годом, а это означает, что программы по прекращению употребления табака в настоящее время являются второй по популярности мерой MPOWER с точки зрения охвата населения. Это произошло благодаря двум крупным странам, Индии и Бразилии, применившим всеобъемлющую поддержку в отказе от курения на уровне передовой практики. В странах с низким и средним уровнями дохода был достигнут значительный прогресс Из 5 миллиардов человек, защищенных по крайней мере одной полноценной мерой MPOWER, 3,9 миллиарда проживают в странах с низким и средним уровнями дохода. Бразилия и Турция, единственные две страны, которые приняли все меры MPOWER на самом высоком уровне, являются странами со средним уровнем дохода. В целом, 61% населения, проживающего в странах с низким и средним уровнями дохода, защищены по крайней мере одной полноценной мерой MPOWER, а 44% защищены по крайней мере двумя полноценными мерами MPOWER. За период после 2007 года в странах с низким уровнем дохода произошли значительные улучшения, когда только в трех из 34 стран с таким уровнем дохода применялась единственная мера MPOWER. Сегодня половина (17) всех стран с низким уровнем дохода применяет хотя бы одну из мер на уровне передовой практики. В настоящее время в восьми странах с низким уровнем дохода действует одна мера, соответствующая уровню передовой практики, в пяти странах — две меры, в трех странах (Чад, Непал, Сенегал) — три, и в одной стране (Мадагаскар) — четыре меры. К сожалению, из 17 стран с низким уровнем дохода, в которых не приняты меры на уровне передовой практики, только три страны осуществляют программу борьбы против табака силами своих Министерств здравоохранения, имея в штате как минимум пять сотрудников в пересчете на занятых полное рабочее время. С тех пор, как в 2007 году была представлена стратегия MPOWER в качестве инструмента оказания помощи странам в осуществлении мер РКБТ ВОЗ по сокращению спроса на табачные изделия, был достигнут значительный прогресс в глобальной борьбе против табака. Пять миллиардов человек — около 65% населения мира — в настоящее время охвачены как минимум одной мерой MPOWER, реализованной на самом высоком уровне. Это число увеличилось более чем в четыре раза за период после 2007 года, когда только 1 миллиард человек — 15% населения мира — были защищены хотя бы одной мерой MPOWER (не включая мониторинг или кампании в средствах массовой информации, которые оцениваются отдельно). Со времени выхода два года назад последнего Доклада ВОЗ о глобальной табачной эпидемии наблюдается стабильный прогресс: 15 стран, ранее не использовавших эффективные меры борьбы против табака, предприняли действия для достижения уровня передовой практики в применении одной или нескольких мер, а еще 21 страна, применявшая хотя бы одну меру, ввела как минимум еще одну. Это означает, что в период с 2016 по 2018 год в общей ДОЛЯ МИРОВОГО НАСЕЛЕНИЯ, ОХВАЧЕННОГО ОТДЕЛЬНЫМИ МЕРАМИ ПОЛИТИКИ ПО БОРЬБЕ ПРОТИВ ТАБАКА, 2018 ГОД W 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я м ир ов ог о на се ле ни я 22% P Среда, свободная от табачного дыма 32% O Программы по прекращению курения 52% Предупреждения на упаковках 24% Кампании в СМИ E Запреты на рекламу 18% 14% R Налого- обложение M Мониторинг 38% Примечание: Меры политики по борьбе против табака, представленные на этой диаграмме, соответствуют наивысшему уровню достижений в их реализации на национальном уровне; определения категорий этих наивысших достижений представлены в Техническом примечании I. Пять миллиардов человек — около 65% населения мира — в настоящее время охвачены как минимум одной мерой MPOWER, реализованной на самом высоком уровне. 20 21ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Страны во всех регионах мира принимают новые меры Со времени выхода последнего доклада каждая мера MPOWER была принята новыми странами на уровне передовой практики: n Семь стран (Антигуа и Барбуда, Бенин, Бурунди, Гайана, Гамбия, Ниуэ и Таджикистан) недавно приняли всеобъемлющие законы об обеспечении бездымной среды, охватывающие все закрытые общественные места и рабочие места внутри помещений. n Четыре страны (Саудовская Аравия, Словакия, Чешская Республика и Швеция) вышли на уровень передовой практики в области оказания услуг по прекращению употребления табака. Однако за тот же период шесть других стран выбыли из группы стран с наивысшими достижениями по этому показателю, что привело к уменьшению численности этой группы на две страны. n Четырнадцать стран (Барбадос, Гайана, Гондурас, Грузия, Испания, Камерун, Кипр, Люксембург, Пакистан, РЕАЛИЗАЦИЯ КАК МИНИМУМ ДВУХ МЕР MPOWER НА САМОМ ВЫСОКОМ УРОВНЕ ДОСТИЖЕНИЙ (2007–2018 ГОДЫ) 0.5 0.5 0.9 1.1 1.4 3.2 3.4 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 0 1 2 3 4 5 6 7 8 2007 2008 2010 2012 2014 2016 2018 Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Население (миллиарды) Страны 11 15 26 37 46 70 82 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 Саудовская Аравия, Сент-Люсия, Словения, Тимор-Лешти и Хорватия) ввели обязательное размещение крупных графических предупреждений на упаковках табачных изделий, включая использование простой упаковки в Саудовской Аравии. n Десять стран (Антигуа и Барбуда, Азербайджан, Бенин, Гайана, Гамбия, Демократическая Республика Конго, Конго, Ниуэ, Саудовская Аравия и Словения) ввели полный запрет на рекламу, стимулирование продажи и спонсорство табачных изделий (TAPS), в том числе в пунктах продажи. n Десять стран (Австралия, Андорра, Бразилия, Египет, Колумбия, Маврикий, Новая Зеландия, Северная Македония, Таиланд и Черногория) перешли в группу стран с наивысшими достижениями в отношении налогообложения, и ставка налога на табачные изделия в этих странах составляет не менее 75% их розничной цены. Более половины населения мира — 3,9 миллиарда человек, проживающих в 91 стране, — видят крупные графические предупреждения на упаковках табачных изделий со всеми рекомендованными характеристиками, что делает эти предупреждения мерой MPOWER, охватывающей наибольшее число людей и стран. Важно также отметить, что к концу 2018 года 10 стран (Австралия, Венгрия, Ирландия, Новая Зеландия, Норвегия, Саудовская Аравия, Соединенное Королевство, Таиланд, Уругвай и Франция) приняли законы, предусматривающие обязательное использование простой упаковки табачных изделий, и выпустили нормативные положения с указанием сроков ее внедрения. Законодательство об использовании простой упаковки табачных изделий также находится в стадии разработки по меньшей мере еще в девяти других странах. В 62 странах, которые полностью запретили курение в общественных местах и на рабочих местах, проживает 1,6 миллиарда человек, что делает эту меру второй наиболее часто принимаемой странами мерой MPOWER. РЕАЛИЗАЦИЯ КАК МИНИМУМ ОДНОЙ МЕРЫ MPOWER НА САМОМ ВЫСОКОМ УРОВНЕ ДОСТИЖЕНИЙ (2007–2018 ГОДЫ) 0 1 2 3 4 5 6 7 8 1.1 1.8 2.2 2.4 2.8 4.8 5.0 2007 2008 2010 2012 2014 2016 2018 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 75 55 43 92 106 121 136 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 Население (миллиарды) Страны СИТУАЦИЯ С ОСУЩЕСТВЛЕНИЕМ ОТДЕЛЬНЫХ МЕР ПОЛИТИКИ ПО БОРЬБЕ ПРОТИВ ТАБАКА В МИРЕ, 2018 ГОД P Среда, свободная от табачного дыма O Программы по прекращению курения Предупрежде- ния на упаковках W Кампании в СМИ E Запреты на рекламу R Налого- обложение 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) Данные не представлены / не разбиты по категориям Меры политики отсутствуют или неэффективны Минимальные меры политики Умеренные меры политики Полный комплекс мер политики Примечание: Бруней-Даруссалам и Бутан исключены из статистики в отношении меры R, поскольку продажа сигарет в этих странах запрещена. Определения категорий представлены в Техническом примечании I. 53 23 43 91 23 44 24 1 43 27 10 8 62 23 91 29 32 39 38 48 116 32 14 28 103 62 61 M Мониторинг 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи 59 35 74 27 100% 22 23ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД УВЕЛИЧЕНИЕ ДОЛИ МИРОВОГО НАСЕЛЕНИЯ, ОХВАЧЕННОГО ОТДЕЛЬНЫМИ МЕРАМИ ПОЛИТИКИ ПО БОРЬБЕ ПРОТИВ ТАБАКА, ЗА ПЕРИОД С 2016 ПО 2018 ГОД До ля м ир ов ог о на се ле ни я E Запреты на рекламу R Налого- обложение O Программы по прекращению курения Предупреждения на упаковках W 48% 4% Кампании в СМИ 2018 2016 P Среда, свободная от табачного дыма M Мониторинг 2%42% -4% * 0% -1% * -21% * Примечание: Меры политики по борьбе против табака, представленные на этой диаграмме, соответствует наивысшему уровню достижений в их реализации на национальном уровне; определения категорий этих высших достижений представлены в Техническом примечании I. * Доля мирового населения, охваченного этой мерой, снизилась за время после 2016 года. 16% 2% 8% 32% 22% 45% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6% УВЕЛИЧЕНИЕ ДОЛИ МИРОВОГО НАСЕЛЕНИЯ, ОХВАЧЕННОГО ОТДЕЛЬНЫМИ МЕРАМИ ПОЛИТИКИ ПО БОРЬБЕ ПРОТИВ ТАБАКА, ЗА ПЕРИОД С 2007* ПО 2018 ГОД До ля м ир ов ог о на се ле ни я R Налого- обложение E Запреты на рекламу O Программы по прекращению курения W 4% 2018 2007 P Среда, свободная от табачного дыма M Мониторинг 21% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 21% 3% 17% 19% 5% 26% 5% 47% 15% 7% 7% 3% Примечание: Меры политики по борьбе против табака, представленные на этой диаграмме, соответствует наивысшему уровню достижений в их реализации на национальном уровне. * Охват кампаниями в СМИ относится к 2010, а не к 2007 году. Налогообложение относится к 2008, а не к 2007 году. # Численность населения, охваченного кампаниями в СМИ, сократилась за время после 2010 года. Предупрежде- ния на упаковках Кампании в СМИ -10%# 33% положения запрета устанавливаются и принимаются, становится проще довести его до уровня передовой практики. В то время как только 38 стран взимают налоги на табачные изделия на уровне, превышающем рекомендованные ВОЗ 75% от розничной цены пачки сигарет, еще 62 страны взимают налоги, составляющие от 50% до 75% розничной цены, а еще 61 страна взимает налоги в размере от 25% до 50%. По сути, эти страны имеют хорошие возможности для дальнейшего повышения налогов, поскольку налогообложение табачных изделий получает все более широкую поддержку. Численность населения, охваченного мерами защиты, растет Начиная с 2016 года, 14 новых стран приняли соответствующие уровню передовой практики законы в отношении использования крупных графических предупреждений на упаковках табачных изделий, что стало самой популярной мерой MPOWER за последние 2 года. Запреты на рекламу, принятые на уровне передовой практики, также показали двузначный рост: еще 10 стран ввели полные запреты TAPS. Охват населения семи стран двумя мерами MPOWER — создание среды, свободной от табачного дыма, и повышение налогов на табачные изделия — впервые вышел на уровень передовой практики. Наибольший рост охвата населения в период после 2016 года наблюдался в сфере налогообложения табачных изделий. Охват населения этой мерой MPOWER почти удвоился с 8% в 2016 году до 14% в 2018 году. Несмотря на это, налогообложение, хотя и является наиболее эффективным способом сокращения употребления табака, по-прежнему является мерой MPOWER с самым низким охватом населения. Население, охваченное предупреждениями на упаковках, увеличилось на 4%, а население, охваченное запретами на рекламу, увеличилось на 2%. Хотя семь стран ужесточили свои законы о создании среды, свободной от табачного дыма, чтобы они соответствовали уровню передовой практики, охват населения заметно не изменился, поскольку эти страны не были густонаселенными. За период после 2016 года численность населения, охваченного мерами в отношении Мониторинга употребления табака и стратегий профилактики, Программами по прекращению курения и Кампаниями в средствах массовой информации, сократилась. Охват программами по прекращению употребления табака снизился на 1% из-за выхода двух стран из группы стран с передовой практикой. Снижение охвата мониторингом, скорее всего, не является истинным снижением, так как после завершения полевых исследований публикация результатов опросов обычно занимает 1–3 года, и только после этого они будут представлены здесь. Принятие неполных или частичных мер политики является первым шагом на пути к реализации полного комплекса мер борьбы против табака Даже там, где уровень передовой практики еще не достигнут, каждой из мер MPOWER уделялось определенное внимание в большинстве стран мира. В дополнение к 62 странам, принявшим всеобъемлющие законы об обеспечении среды, свободной от табачного дыма, в 70 странах действуют законы с минимальными или недостаточно жесткими требованиями, запрещающими курение в некоторых, но не во всех общественных местах и на рабочих местах, что закладывает основу для принятия полноценного и действенного закона в будущем. Это говорит о том, что, хотя частичные запреты в настоящее время не обеспечивают эффективной защиты населения этих стран от вредного воздействия вторичного табачного дыма, растущая общественная поддержка будет означать, что для большинства из этих стран потребуются внести только поправки к существующему закону, тогда как в других странах будет необходимо принятие нового закона. В то время как только в 23 странах существуют меры поддержки в отказе от употребления табака, соответствующие уровню передовой практики, еще в 116 странах в медицинских учреждениях предоставляются услуги для бросающих курить с полной или частичной компенсацией затрат, и еще в 32 странах предоставляются такие услуги, но не компенсируется их стоимость. Таким образом, в общей сложности в 171 стране потребители табака, желающие бросить курить, могут получить поддержку определенного уровня. Наряду с 91 страной, в которых является обязательным наличие убедительных графических предупреждений о вреде для здоровья на пачках сигарет, в 61 другой стране действуют законы с минимальными или недостаточно жесткими требованиями в отношении использования каких-либо предупреждений на пачках. Использование этих менее заметных предупреждений, хотя и не столь эффективных, как предупреждения, соответствующие лучшим образцам, показывает, что предпринимаются определенные шаги по информированию потребителей табака об опасностях его употребления, а также дает возможность этой 61 стране сделать в будущем свои обязательные предупреждения более убедительными и соответствующими уровню передовой практики. В дополнение к 48 странам, которые ввели запрет TAPS, еще в 103 странах действуют частичные запреты TAPS, поэтому по крайней мере некоторые формы рекламы, стимулирования продажи и спонсорства табачных изделий уже являются незаконными — и как только основные 24 25ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Поэтому результаты некоторых опросов, которые проводились в 2017 и 2018 годах, не будут отражены до выхода следующего Доклада ВОЗ о глобальной табачной эпидемии в 2021 году. Снижение охвата населения кампаниями в средствах массовой информации на 21% вызывает обеспокоенность, поскольку регулярное проведение таких кампаний имеет решающее значение для поддержания открытого диалога с населением о вреде табака и необходимости дальнейших усилий по борьбе с ним. Вдохновляет тот факт, что в 91 стране действуют требования в отношении использования крупных графических предупреждений на упаковках табачных изделий, что делает эту меру наиболее распространенной на сегодняшний день. Из всех мер стратегии MPOWER с момента ее появления требование об использовании графических предупреждений на упаковках приняло самое большое число стран, и в настоящее время еще 82 страны охвачены этой мерой на уровне передовой практики, по сравнению всего с девятью странами в 2007 году. За этим последовало введение требований о запрете курения в общественных местах и на рабочих местах, которые приняты еще 52 странами на уровне передовой практики, по сравнению с 10 странами в 2007 году, а также введение запретов на рекламу, стимулирование продажи и спонсорство табачных изделий, принятых еще 41 страной, по сравнению с 7 странами в 2007 году. Некоторые страны еще не приняли ни одной меры MPOWER Все страны имеют возможность осуществлять жесткие меры политики по борьбе против табака для защиты своего населения от употребления табака и вредного воздействия вторичного табачного дыма, а также от болезней, инвалидности и смерти, причиной которых они являются. Несмотря на то что с 2007 года принятие всеобъемлющих стратегий борьбы против табака неуклонно продвигается вперед, предстоит еще многое сделать. Пятьдесят девять стран еще не приняли ни одной меры MPOWER на самом высоком уровне достижений в ее реализации, и 49 из них являются странами с низким и средним уровнями дохода. Кроме того, темпы прогресса в принятии некоторых мер MPOWER были ниже по отношению к реализации других мер. Например, введение полных запретов TAPS и повышение налогов на табачные изделия до достаточно высоких уровней в большинстве стран происходит слишком медленно. Пятьдесят девять стран еще не приняли ни одной меры MPOWER на самом высоком уровне достижений в ее реализации. 26 27ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Рамочная конвенция ВОЗ по борьбе против табака и Протокол о ликвидации незаконной торговли табачными изделиями Ратифицировав РКБТ ВОЗ, страны твердо заявили о своей приверженности сдерживанию табачной эпидемии. В мае 2003 года государства-члены ВОЗ вошли в историю, приняв Рамочную конвенцию ВОЗ по борьбе против табака (РКБТ ВОЗ) (1) — первый существующий на сегодняшний день договор, конкретно касающийся общественного здравоохранения. К настоящему моменту 181 Сторона подписала РКБТ ВОЗ, что позволяет ей охватить более 90% населения земного шара. Это один из наиболее широко применяемых документов Организации Объединенных Наций. В ходе переговоров по принятию РКБТ ВОЗ страны заняли смелую и дальновидную позицию в отношении табачной промышленности, которая, как признается в ее собственных внутренних документах, в погоне за прибылью производит вызывающие привыкание, смертоносные изделия. На протяжении десятилетий эта промышленность нацелена на наиболее уязвимые группы населения — женщин, детей и малоимущих людей — с помощью тщательно продуманных рекламных кампаний, чтобы обеспечить себе полное завоевание рынка сбыта. Табачные компании также умело изменили дизайн своей продукции, чтобы добиться наиболее сильного привыкания к ней у ее потребителей. РКБТ ВОЗ также создала форум для обсуждения и решения новых проблем по мере их возникновения, например, продвижения на новые рынки табачных изделий из традиционных культур, таких как наргиле и бездымный табак, а также сотен разновидностей и брендов новых продуктов, таких как электронные системы доставки никотина и изделия из нагреваемого табака. Эти новые проблемы указывают на необходимость дальнейшего регулирования табачных изделий. Ратифицировав РКБТ ВОЗ, страны твердо заявили о своей приверженности сдерживанию табачной эпидемии. Как бы ни была эффективна РКБТ ВОЗ, ее Стороны признают, что существуют аспекты борьбы против табака, которые требуют принятия специально подобранных ответных мер. Одним из таких аспектов является незаконная (зачастую трансграничная) торговля табачными изделиями. Эта торговля представляет серьезную угрозу для общественного здравоохранения, поскольку она срывает осуществление жестких антитабачных мер, таких как использование наглядных предупреждений о вреде для здоровья на табачных упаковках, и расширяет доступ к зачастую более дешевым табачным изделиям, тем самым увеличивая масштабы табачной эпидемии и подрывая политику борьбы против табака. Это также приводит к значительным потерям государственных доходов и в то же время способствует финансированию международной преступной деятельности. Этот вопрос настолько серьезен, что Стороны Конвенции вели переговоры о новом международном договоре, дополняющем РКБТ ВОЗ. Протокол о ликвидации незаконной торговли табачными изделиями Протокол о ликвидации незаконной торговли табачными изделиями (2) является первым протоколом к РКБТ ВОЗ. Протокол был принят на основе консенсуса на пятой сессии Конференции Сторон в 2012 году и в настоящее время насчитывает 55 Сторон. Имея юридически обязательный характер, Протокол устанавливает правовые обязательства во многом так же, как и сама РКБТ ВОЗ. Протокол направлен на ликвидацию всех форм незаконной торговли табачными изделиями. Он предоставляет инструменты для предотвращения незаконной торговли путем обеспечения надежности цепи поставок табачных изделий, включая лицензирование и создание международной системы отслеживания и прослеживания, а также противодействие незаконной торговле с помощью сдерживающих правоохранительных мер и комплекса мероприятий, способствующих международному сотрудничеству. Этот новый договор в качестве самостоятельного юридического документа вступил в силу в 2018 году. Первая сессия Совещания Сторон (СС1) Протокола была проведена в Женеве сразу после его вступления в силу (3, 4). Отражая саму РКБТ ВОЗ, протокол состоит из 10 частей. Он содержит введение и общие обязательства (Части I и II), основные части, включающие контроль цепи поставок, правонарушения и международное сотрудничество (Части III, IV и V) и отчетность (Часть VI). Части VII, VIII, IX и X охватывают институциональные механизмы, урегулирование споров, разработку Протокола и заключительные положения. Примеры тем, рассматриваемых в 47 положениях Протокола, включают систему лицензирования, равноценного санкционирования или контроля (Статья 6); отслеживание и прослеживание (Статья 8); беспошлинные продажи (Статья 13); противоправные деяния, включая уголовные правонарушения (Статья 14); помощь и сотрудничество, включая взаимную административную помощь (Статья 28) и взаимную правовую помощь (Статья 29). Части Рамочной конвенции ВОЗ по борьбе против табака РКБТ ВОЗ уникальна среди других рамочных конвенций по глубине и широте основных обязательств, содержащихся в ней как в отношении спроса на табак, так и в отношении его предложения. Сокращение спроса n Статья 6. Ценовые и налоговые меры по сокращению спроса на табак n Статья 7. Неценовые меры по сокращению спроса на табак n Статья 8. Защита от воздействия табачного дыма n Статья 9. Регулирование состава табачных изделий n Статья 10. Регулирование раскрытия состава табачных изделий n Статья 11. Упаковка и маркировка табачных изделий n Статья 12. Просвещение, передача информации, подготовка и информирование населения n Статья 13. Реклама, стимулирование продажи и спонсорство табачных изделий Глобальный прогресс в осуществлении Рамочной конвенции ВОЗ по борьбе против табака (РКБТ ВОЗ) (5) 28 29ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД n Статья 14. Меры по сокращению спроса, касающиеся табачной зависимости и прекращения употребления табака Сокращение предложения n Статья 15. Незаконная торговля табачными изделиями n Статья 16. Продажа несовершеннолетним и несовершеннолетними n Статья 17. Поддержка альтернативных видов экономически жизнеспособной деятельности В рамках своих общих обязательств РКБТ ВОЗ обязывает Стороны защищать разработку и осуществление своей политики от воздействия табачной промышленности (Статья 5.3). С учетом этого РКБТ ВОЗ затрагивает всю цепочку производства, распределения и продажи табачных изделий. Стороны также приняли на основе консенсуса руководящие принципы осуществления основных положений РКБТ ВОЗ, которые помогают им выполнять свои юридические обязательства посредством рекомендуемых действий, подробно описанных в этих положениях. Руководящие принципы были разработаны в рамках межправительственной деятельности и приняты Сторонами на различных сессиях КС. Руководство Рамочной конвенцией ВОЗ по борьбе против табака и Протоколом о ликвидации незаконной торговли табачными изделиями Руководящим органом РКБТ ВОЗ является Конференция Сторон (КС), и в ее состав входят все 181 Сторона. Аналогичным образом, Совещание Сторон (СС) обеспечивает руководство Протоколом о ликвидации незаконной торговли табачными изделиями и включает в себя все Стороны Протокола. Оба органа собираются каждые 2 года, причем последние сессии состоятся в конце 2018 года. Деятельность КС и СС регулируется их соответствующими Правилами процедуры (3, 4). Они регулярно рассматривают осуществление РКБТ ВОЗ и Протокола, а также принимают решения, необходимые для содействия их эффективному осуществлению, включая создание вспомогательных органов, таких как рабочие и экспертные группы (6). Первая сессия Совещания Сторон (СС1) состоялась в Женеве, Швейцария, в октябре 2018 года. Ориентируясь на свои соответствующие документы, КС и СС следят за ходом осуществления РКБТ и Протокола, выявляют проблемы и имеющиеся возможности и анализируют текущую деятельность. Размещенный в штаб-квартире ВОЗ Секретариат Конвенции оказывает поддержку Сторонам обоих договоров, тесно сотрудничая с ВОЗ и наблюдателями в целях обеспечения взаимодополняемости и координации действий. Статья 14 — Меры по сокращению спроса, касающиеся табачной зависимости и прекращения употребления табака В РКБТ ВОЗ прямо говорится о важности сокращения числа нынешних потребителей табака с помощью мер по прекращению курения, изложенных в Статье 14 — «Меры по сокращению спроса, касающиеся табачной зависимости и прекращения употребления табака» (7). В этой статье говорится: 1. Каждая Сторона разрабатывает и распространяет надлежащие, всесторонние и комплексные руководящие принципы, основанные на научных данных и наилучшей практике, с учетом национальных обстоятельств и приоритетов и принимает эффективные меры для содействия прекращению употребления табака и обеспечения адекватного лечения табачной зависимости. 2. Для достижения этой цели каждая Сторона стремится: (a) разработать и осуществить эффективные программы, направленные на содействие прекращению употребления табака, в том числе в таких местах, как учебные заведения, медико-санитарные учреждения, рабочие места и места проведения спортивных мероприятий; (b) включать диагностику и лечение табачной зависимости и услуги по консультированию в отношении прекращения употребления табака в национальные программы, планы и стратегии в области здравоохранения и просвещения при участии, в соответствующих случаях, работников здравоохранения, работников в общинах и социальных работников; (c) создать в учреждениях медико- санитарной помощи и центрах реабилитации программы по диагностике, консультированию, профилактике и лечению табачной зависимости; и (d) сотрудничать с другими Сторонами в облегчении доступа к лечению и доступности по цене лечения табачной зависимости, включая фармацевтические препараты, в соответствии со Статьей 22. Такие препараты и их компоненты могут включать лекарственные средства, препараты, используемые для введения лекарственных средств, а также для диагностики в соответствующих случаях. Хотя Статья 14 является единственной статьей, посвященная прекращению употребления табака, ряд положений РКБТ ВОЗ косвенно относятся к этому вопросу — например, все меры по сокращению спроса на табак будут косвенно влиять на прекращение его употребления. Кроме того, Статья 12 «Просвещение, передача информации, подготовка и информирование населения» содержит ряд положений, направленных на повышение информированности об опасностях употребления табака во всех секторах общества и о пользе прекращения курения для здоровья. Об этом прямо говорится в пункте (b), который обязывает каждую Сторону принимать и осуществлять эффективные законодательные, исполнительные, административные или иные меры, направленные на содействие «информированию населения об опасностях для здоровья потребления табака и воздействия табачного дыма, а также о преимуществах прекращения употребления табака и образа жизни, свободного от табака, как это указано в Статье 14.2» (8). В Статье 14 РКБТ ВОЗ прямо говорится о важности сокращения числа нынешних потребителей табака с помощью мер по прекращению курения. Первая сессия Совещания Сторон (СС1) состоялась в Женеве, Швейцария, в октябре 2018 года. 30 31ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Сводный доклад о глобальном прогрессе в осуществлении Рамочной конвенции ВОЗ по борьбе против табака 2018 года: доклад, составленный на основе информации из системы отчетности по РКБТ ВОЗ На основе докладов Сторон об осуществлении РКБТ ВОЗ, представляемых Конференции Сторон в соответствии со статьей 21 Конвенции, Секретариат Конвенции регулярно готовит двухгодичные сводные доклады о глобальном прогрессе в осуществлении Конвенции. Сводный доклад 2018 года о глобальном прогрессе в осуществлении РКБТ ВОЗ был представлен на КС8 (9). Руководящие принципы осуществления Статьи 14 Конвенции Руководящие принципы осуществления Статьи 14, принятые КС4 в 2010 году в соответствии с решением FCTC/ COP4 (8), призваны «оказывать Сторонам содействие в выполнении ими обязательств, вытекающих из Статьи 14 РКБТ ВОЗ по борьбе против табака, в соответствии с их обязательствами по другим положениям Конвенции и намерениями Конференции Сторон, на основе наилучших имеющихся научных данных и с учетом национальных обстоятельств и приоритетов». Для этого руководящие принципы: (i) призывают Стороны укрепить или создать устойчивую инфраструктуру, мотивирующую попытки прекратить употребление табака, обеспечивающую широкий доступ к поддержке для потребителей табачных изделий, желающих отказаться от их употребления, и являющуюся устойчивым источником ресурсов для обеспечения такой поддержки; (ii) определяют основные эффективные меры, необходимые для содействия прекращению употребления табака и включения лечения табачной зависимости в национальные программы борьбы против табака и системы здравоохранения; и (iii) призывают Стороны делиться опытом и сотрудничать, чтобы содействовать развитию или укреплению поддержки в целях прекращения употребления табака и лечения табачной зависимости. В качестве основы для руководящих принципов Стороны разработали ряд основных рекомендаций для реализации программ по прекращению употребления табака. Принципы, которым Стороны должны следовать при интеграции таких программ в свои системы здравоохранения, включают: n Признание того, что употребление табака вызывает сильную зависимость n Меры по лечению табачной зависимости должны осуществляться синергетически с другими мерами по борьбе против табака n Стратегии прекращения употребления табака и лечения табачной зависимости должны опираться на наилучшие имеющиеся фактические данные об эффективности n Лечение должно быть доступным и приемлемым по цене n Прекращение употребления табака и лечение табачной зависимости должны быть инклюзивными n Важное значение имеют мониторинг и оценка n Активное партнерство с гражданским обществом n Разработка и реализация политики по прекращению употребления табака должны быть защищены от всех коммерческих и корпоративных интересов n Обмен опытом между Сторонами значительно повышает их способность осуществлять руководящие принципы n Важное значение имеет укрепление существующих систем здравоохранения в целях содействия прекращению употребления табака и лечению табачной зависимости. В дополнение к набору определенных терминов каждый основной раздел руководящих принципов включает рекомендации, призванные оказать Сторонам помощь в осуществлении ими Статьи 14 Конвенции. Основные рекомендации заключаются в следующем: Развитие инфраструктуры для цели поддержки прекращения употребления табака и лечения табачной зависимости Предлагаемые действия включают проведение национального ситуационного анализа; налаживание или укрепление национальной координации; разработку и распространение всесторонних руководящих принципов; обращение внимания на употребление табака работниками здравоохранения и другими лицами, причастными к прекращению его употребления; развитие потенциала в области подготовки кадров; использование существующих систем и ресурсов для обеспечения максимально возможного доступа к услугам; введение обязательной регистрации факта употребления табака в медицинских записях; поощрение совместной работы; и создание устойчивого источника финансирования помощи для прекращения употребления табака. Основные элементы системы, призванной помочь потребителям табака отказаться от его употребления Рекомендуется, чтобы поддержка и лечение, направленные на прекращение употребления табака, предоставлялись во всех медико- санитарных учреждениях и всеми поставщиками медицинских услуг. Также следует рассмотреть возможность предоставления такой поддержки и лечения в немедицинских учреждениях должным образом подготовленными лицами, не связанными с оказанием медицинских услуг, особенно в тех случаях, когда научные данные указывают на то, что некоторые группы потребителей табака, возможно, лучше обслуживать таким образом. Действия Сторон включают разработку подходов на уровне всего населения; установление более интенсивных индивидуальных подходов; обеспечение наличия лекарственных препаратов; и учет появляющихся научных данных, новаторских подходов и каналов массовой коммуникации. Развитие поддержки отказа от употребления табака: поэтапный подход Руководящие принципы рекомендуют Сторонам осуществлять меры по содействию прекращению употребления табака и повышению спроса на лечение табачной зависимости, предусмотренные в других статьях РКБТ ВОЗ. Сторонам также следует использовать существующую инфраструктуру как в медицинских, так и в других учреждениях, чтобы обеспечить выявление всех потребителей табака и предоставление им хотя бы кратких консультаций. Действия по достижению этой цели включают создание инфраструктуры и среды, побуждающей предпринимать попытки к отказу от употребления табака, путем установления компонентов системы здравоохранения, способствующих прекращению курения (в том числе посредством адекватного финансирования и профессиональной подготовки); решение проблемы отказа от употребления табака среди самих медицинских работников; и включение кратких консультаций в существующие системы медико-санитарной помощи. Мониторинг и оценка В руководящих принципах Сторонам в целях отслеживания тенденций рекомендуется осуществлять мониторинг и оценку всех стратегий и программ по прекращению употребления табака и лечению табачной зависимости, в том числе промежуточных и итоговых показателей. Кроме того, Стороны должны использовать опыт других стран путем обмена информацией. Для обеспечения эффективного мониторинга и оценки Сторонам следует сформулировать поддающиеся измерению цели, определить потребности в ресурсах и идентифицировать показатели, чтобы иметь возможность оценивать прогресс в направлении достижения каждой цели. Кроме того, Стороны должны побуждать работников здравоохранения и поставщиков медицинских услуг к участию в мониторинге результатов обслуживания с использованием четко определенных показателей и с учетом национальных обстоятельств и приоритетов. Наконец, Сторонам следует использовать практичные и эффективные системы сбора данных, которые опираются на действенные методики и соответствуют местным обстоятельствам. Международное сотрудничество В руководящих принципах Сторонам рекомендуется сотрудничать на международном уровне, чтобы обеспечить себе возможность осуществлять наиболее эффективные меры по прекращению употребления табака. С этой целью Сторонам следует обмениваться своим опытом в области прекращения употребления табака и лечения табачной зависимости с другими Сторонами, в том числе стратегиями развития и финансирования поддержки прекращения употребления табака, национальными руководящими принципами лечения, стратегиями обучения, а также данными и отчетами по результатам оценок систем лечения табачной зависимости. В соответствующих случаях Сторонам предлагается использовать международные механизмы представления отчетности, например регулярные отчеты об осуществлении РКБТ ВОЗ, а также двусторонние и многосторонние контакты и соглашения. Наконец, Сторонам следует периодически проводить обзор и пересмотр этих руководящих принципов, обеспечивая, чтобы они и далее служили для Сторон источником эффективного руководства и помощи. Руководящие принципы осуществления Статьи 14. В качестве основы для руководящих принципов Стороны разработали ряд основных рекомендаций для реализации программ по прекращению употребления табака. 32 33ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД РКБТ 2030 В рамках проекта оказания помощи в целях развития под названием РКБТ 2030 (10) Секретариат Конвенции оказывает поддержку 15 странам с низким и средним уровнями дохода в укреплении осуществления РКБТ ВОЗ путем интеграции борьбы против табака с другими мероприятиями в области здравоохранения и развития. Многие страны-партнеры РКБТ 2030 работают над созданием и реализацией программ прекращения употребления табака в соответствии со Статьей 14 РКБТ ВОЗ, а Секретариат Конвенции сотрудничает с правительствами стран-партнеров РКБТ 2030 в целях содействия интеграции мер по прекращению употребления табака в системы первичной медико-санитарной помощи. В качестве примеров результатов этого проекта можно привести разработку онлайн-курса по прекращению употребления табака в Колумбии и проведение семинаров по обучению преподавателей из числа медицинских работников во всех семи провинциях Непала. В рамках проекта РКБТ 2030 Секретариат Конвенции также сотрудничал с Программой развития Организации Объединенных Наций (ПРООН) в составлении краткого информационного бюллетеня, выпущенного с целью повышения информированности о вариантах включения мероприятий по прекращению употребления табака в гранты Глобального фонда для борьбы со СПИДом, туберкулезом и малярией (11). В документе описывается, как потребление табака ухудшает исходы болезней у людей с туберкулезом и ВИЧ, и как включение мер борьбы против табака в эти гранты может принести больше пользы для здоровья таких пациентов и повысить эффективность их лечения. Групповое занятие в рамках программы прекращения курения, проводимой в «Центрах профилактики и лечения наркомании» в Сальвадоре Глобальная приверженность осуществлению РКБТ ВОЗ Каждый из итоговых документов трех совещаний высокого уровня по неинфекционным заболеваниям, проведенных Генеральной Ассамблеей Организации Объединенных Наций (ГА ООН), поддержал и призвал страны к осуществлению РКБТ ВОЗ. Такой же подход был применен государствами- членами ООН при принятии повестки дня в отношении Целей в области устойчивого развития (ЦУР), упрощая осуществление РКБТ ВОЗ с помощью Задачи 3A: «активизировать при необходимости осуществление РКБТ ВОЗ во всех странах». Кроме того, восьмая Конференция сторон РКБТ ВОЗ приняла Глобальную стратегию по ускорению борьбы против табака: содействие устойчивому развитию путем осуществления РКБТ ВОЗ, 2019–2025 гг. (12). Задача 3.4 К 2030 году уменьшить на треть преждевременную смертность от НИЗ Задача 3A Активизировать осуществление РКБТ ВОЗ 34 35ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Предложение помощи в целях прекращения употребления табака Поддержка прекращения употребления табака может более чем в два раза увеличить шансы на успешный отказ от этой привычки почти у 60% подростков формируется никотиновая зависимость (18). Большинство людей, которые употребляют табак регулярно, делают это потому, что они зависимы от никотина и, следовательно, могут извлечь большую пользу из целого ряда эффективных мер по прекращению употребления табака. Например, меры по прекращению курения, реализованные на самом высоком уровне в 14 странах с 2007 по 2014 год, приведут к тому, что в будущем к 2030 году число смертей, связанных с табаком, сократится примерно на 1,5 миллиона (19). Отказ от употребления табака приносит людям немедленную пользу для здоровья Люди начинают ощущать благотворный эффект в течение нескольких часов или даже минут после отказа от употребления табака. Можно ожидать, что отказ от табака всего на один день поможет снизить частоту сердечных сокращений и артериальное давление, а уровень окиси углерода в крови вернется к норме (20). У человека, бросившего курить, в течение 3-х месяцев улучшается работа сердца и легких. Кашель и одышка обычно уменьшаются в течение 1–9 месяцев после отказа от курения (20). Риск смерти из-за употребления табака также начинает снижаться вскоре после прекращения курения. Современные данные свидетельствуют о том, что риск смерти от ишемической болезни сердца снижается в два раза в течение 5 лет после отказа от курения, а риск возникновения инсульта становится в течение 5–15 лет таким же, как и у никогда не курившего человека. Даже риск смерти от рака легкого снижается на 30–50% в течение 10 лет после отказа от курения (20). Эффективные услуги по прекращению курения спасают жизни, улучшают здоровье и экономят денежные средства Люди, отказавшиеся от употребления табака, могут жить дольше, быть более здоровыми и продуктивными. Отказ от курения в любой момент жизни может увеличить Успех политики борьбы против табака привел к увеличению спроса на поддержку в прекращении его употребления. Поддержка в отказе от табака должна быть легкодоступной, чтобы оказывать большее влияние на сокращение распространенности его употребления. Многие потребители табака хотят бросить курить, и для этого им нужна помощь В мире насчитывается 1,1 миллиарда взрослых курильщиков и не менее 367 миллионов потребителей бездымного табака (13), многие из которых говорят, что хотят или намереваются отказаться от употребления табака (14, 15). Хотя этот факт и обнадеживает, поддержка прекращения употребления табака во всем мире остается на очень низком уровне, и многие люди не имеют доступной адекватной поддержки в отказе от курения. В настоящее время около 30% населения мира имеет доступ к надлежащим услугам по прекращению употребления табака (16). За последнее десятилетие страны добились значительного прогресса в разработке научно обоснованных и экономически эффективных мер борьбы против табака. В целом ряде стран многие закрытые общественные места теперь свободны от табачного дыма, предупреждения об опасностях, связанных с употреблением табака, появляются на упаковках табачных изделий и в сообщениях средств массовой информации, более высокие цены и налоги на табачные изделия снизили их ценовую доступность, а реклама, стимулирование продажи и спонсорство табачных изделий были запрещены. Все эти усилия способствовали снижению спроса на табачные изделия и увеличили число сегодняшних потребителей табака, намеревающихся бросить курить. В среднем по странам, где проводился Глобальный опрос взрослого населения о потреблении КАК ОТКАЗ ОТ УПОТРЕБЛЕНИЯ ТАБАКА ПОМОГАЕТ ВАШЕМУ ОРГАНИЗМУ (20–25) Источник: Глобальный опрос взрослого населения о потреблении табака (14). a Доля курильщиков включает тех, кто указал, что намеревается бросить курить в следующем месяце, в течение следующих 12 месяцев или когда-нибудь в будущем. табака, более 60% курильщиков указали, что они намерены бросить курить, и более 40% пытались бросить курить в течение 12 месяцев, предшествовавших опросу. Услуги по поддержке прекращения употребления табака дополняют меры стран по борьбе против табака и могут способствовать сокращению распространенности его употребления. Поддержка прекращения употребления табака помогает его потребителям отказаться от этой привычки Никотин, фармакологически активный препарат, который естественным образом содержится в табачном растении, вызывает сильное привыкание и быстро попадает в мозг после вдыхания или проглатывания табачных продуктов или употребления нетабачных продуктов, содержащих никотин (17). Никотин вызывает такое сильное привыкание, что способность четверти подростков самостоятельно отказаться от употребления табака начинает уменьшаться после выкуривания всего трех-четырех сигарет, а после выкуривания пяти пачек Преимущества отказа от курения для здоровья всех потребителей табака бывают незамедлительными и отдаленными В течение 20 минут уменьшается частота сердечных сокращений и снижается артериальное давление (22). В течение 12 часов уровень окиси углерода в крови опускается до нормальных значений (23). Через 2-12 недель после отказа от употребления табака улучшается работа сердца и легких (20). Через 6 недель после отказа от употребления бездымного табака 97% лейкоплакических поражений полости рта полностью разрешаются (24). Через 1-9 месяцев после отказа от курения уменьшаются кашель и одышка (20). Через 1 год после отказа от курения риск развития ишемической болезни сердца примерно в два раза меньше, чем у курильщика (20). Через 1-4 года после отказа от употребления бездымного табака риск смерти снижается почти в два раза по сравнению с таким риском у человека, который продолжает употреблять бездымный табак (25). Через 5-15 лет после отказа от курения риск смерти от ишемической болезни сердца снижается в два раза, риск возникновения инсульта становится таким же, как и некурящего человека (20). Через 10 лет после отказа от курения риск развития рака легкого снижается примерно в два раза по сравнению с таким риском у курильщика, и также снижается риск развития рака полости рта, горла, пищевода, мочевого пузыря, шейки матки и поджелудочной железы (20). Через 15 лет после отказа от курения риск развития ишемической болезни сердца становится таким же, как и у никогда не курившего человека (20). ДОЛЯ НЫНЕШНИХ КУРИЛЬЩИКОВ, КОТОРЫЕ НАМЕРЕНЫ БРОСИТЬ КУРИТЬ (СТРАНЫ, ПРЕДСТАВИВШИЕ ДАННЫЕ ГЛОБАЛЬНОГО ОПРОСА ВЗРОСЛОГО НАСЕЛЕНИЯ О ПОТРЕБЛЕНИИ ТАБАКА ЗА РАЗНЫЕ ГОДЫ)a Пакистан 2014 Китай 2010 Египет 2009 Индонезия 2011 Индия 2017 Польша 2010 Бразилия 2008 Греция 2013 Вьетнам 2015 Таиланд 2011 Турция 2012 Российская Федерация 2016 Филиппины 2015 Румыния 2011 Уганда 2013 Казахстан 2014 Панама 2013 Бангладеш 2017 Камерун 2013 Нигерия 2012 Катар 2013 Эфиопия 2016 Украина 2017 Малайзия 2011 Уругвай 2017 Коста-Рика 2015 Аргентина 2012 Кения 2014 Мексика 2015 Сенегал 2015 Ботсвана 2017 0 10 20 30 40 50 60 70 80 90 36 37ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ее продолжительность — например, отказ от курения в 30-летнем возрасте может увеличить ожидаемую продолжительность жизни до 10 лет. Даже в возрасте 50 лет отказ от курения приводит к увеличению ожидаемой продолжительности жизни в среднем на 6 лет (21). Другими словами, никогда не поздно извлечь пользу для здоровья в результате отказа от употребления табака. Можно также ожидать, что приобретенные годы жизни будут более здоровыми, поскольку болезни, вызываемые употреблением табака, обычно являются хроническими и изнурительными и приводят к снижению качества жизни. Таким образом, отказ от курения может снизить затраты на медицинское обслуживание, связанные с длительными заболеваниями, а также увеличить продолжительность экономически и социально продуктивной жизни. Увеличение числа людей, бросивших курить, также принесет пользу экономике. В 2012 году расходы на здравоохранение, связанные с заболеваниями, вызываемыми курением, составили в мировом масштабе 422 миллиарда долларов США. Если принять во внимание потерю производительности труда из-за болезней и смертей, связанных с курением, то эти затраты оцениваются в 1436 миллиардов долларов США, причем почти 40% этих расходов приходится на страны с низким и средним уровнями дохода (26). Таким образом, сокращение потребления табака путем реализации всесторонних антитабачных мер, включая предложение помощи в отказе от курения, может обеспечить значительную экономию финансовых средств как для стран, так и для бывших потребителей табака. В одном датском исследовании предполагаемая общая экономия расходов страны на медицинское обслуживание умеренного курильщика, бросившего курить в возрасте 35 лет, составила 24 800 евро для мужчин и 34 100 евро для женщин (27). Оказание поддержки потребителям табака в отказе от его употребления является неотъемлемой частью глобальной повестки дня в области здравоохранения В соответствии с Политической декларацией по неинфекционным заболеваниям, принятой Генеральной Ассамблеей ООН в 2011 году, ВОЗ разработала девять добровольных глобальных целей по снижению во всем мире смертности от четырех основных неинфекционных заболеваний (НИЗ) — сердечно-сосудистых заболеваний, рака, хронических заболеваний легких и диабета — и ускорению действий по борьбе с ведущими факторами риска возникновения НИЗ. Согласованной целью борьбы против табака является относительное сокращение на 30% распространенности употребления табака (ежедневного и эпизодического) среди лиц в возрасте 15 лет и старше в период с 2010 по 2025 год, что было одобрено Всемирной ассамблеей здравоохранения в мае 2013 года. Для достижения этой цели важно не только предотвратить употребление табака, но и добиться того, чтобы большее число потребителей табака бросили курить. Сегодня существует целый ряд высокоэффективных и недорогих мер, которые помогают в этом. Важность оказания помощи нынешним потребителям табака в отказе от курения отражена в Глобальном плане действий ВОЗ по профилактике НИЗ и борьбе с ними на 2013–2020 годы (28). В Глобальном плане действий перечислены «наиболее выгодные» и экономически эффективные варианты политики для стран по снижению бремени НИЗ. В их число входит рекомендация о том, что страны должны «предоставлять оплачиваемую, эффективную и охватывающую все население поддержку в прекращении употребления табака (включая краткие консультации, национальную бесплатную телефонную линию для бросающих курить и мобильный сервис по отказу от курения (mCessation)) всем тем, кто хочет бросить курить» (28). Цели в области устойчивого развития (ЦУР) подчеркивают необходимость принятия всеми странами решительных мер по сокращению потребления табака, призывая — в качестве конкретной задачи в рамках ЦУР 3 о хорошем здоровье и благополучии — к более активному осуществлению Рамочной конвенции ВОЗ по борьбе против табака (РКБТ) во всем мире. В Статье 14 РКБТ ВОЗ говорится о необходимости осуществления мер по прекращению употребления табака и предоставления услуг для бросающих курить с компенсацией их затрат, а также о средствах для достижения этой цели. Несмотря на эти обязательства, прогресс в использовании передовой практики при оказании поддержки в отказе от курения в странах замедлился по сравнению с прогрессом в отношении применения других мер MPOWER (таких как места, свободные от табачного дыма, и запреты на рекламу, стимулирование продажи и спонсорство табачных изделий). Существуют эффективные меры по отказу от употребления табака Существует широкий выбор поведенческих и фармакологических мер по прекращению употребления табака При отсутствии поддержки в прекращении употребления табака всего 4% попыток бросить курить оказываются успешными (29). Доказавшие свою эффективность лекарственные препараты, помогающие бросить курить, и профессиональная поддержка могут удвоить шансы потребителя табака на успешный отказ от курения (30). Был разработан целый ряд различных подходов с целью помочь людям отказаться от употребления табака. Они различаются по силе воздействия, стоимости и эффективности и в широком смысле могут быть классифицированы как поведенческие или фармакологические меры. Поведенческие меры Хотя поведенческие меры по прекращению употребления табака, как правило, не требуют больших затрат, они могут быть очень эффективными. Проведение кратких консультаций медицинскими работниками в рамках их обычных консультаций или общения с пациентами — это подход, в котором используются существующие системы здравоохранения. Когда потребитель табака посещает учреждение первичной или специализированной медицинской помощи, это дает медицинскому работнику возможность предложить и предоставить ему индивидуальную консультацию. Краткая консультация является основным средством мотивации и побуждения к отказу от курения людей, которые иначе не обратились бы за поддержкой в прекращении употребления табака, и как таковая является важным компонентом услуг по прекращению курения. Страны могут легко обучить своих врачей и медицинских работников методам предоставления кратких консультаций населению, которое они обслуживают. Бесплатные телефонные линии для бросающих курить — это удобный способ для потребителей табака, готовых бросить курить, получить доступ к краткому и потенциально интенсивному консультированию в отношении их поведения. Люди, которые использует эти телефонные линии, увеличивают свой абсолютный показатель отказа от курения на 4 процентных пункта, и это говорит о том, что они бросают курить в два раза чаще, чем те, кто пытается Подходы на уровне всего населения Краткая консультация Консультация, рекомендующая отказаться от употребления табака, обычно занимающая всего несколько минут, дается всем потребителям табака в ходе обычной консультации и/или общения с врачом или медицинским работником. Телефонные линии для бросающих курить Бесплатная национальная телефонная линия для бросающих курить — это служба консультирования по телефону, которая может предоставлять как реагирующее, так и инициативное консультирование. Реагирующая линия обеспечивает незамедлительную реакцию на звонок, инициированный потребителем табака, однако отвечает лишь на входящие звонки. Инициативная линия предполагает установление графика плановых звонков для оказания постоянной поддержки тем потребителям табака, которые уже обращались за помощью. Мобильный сервис по отказу от курения (mCessation) Мероприятия по прекращению употребления табака осуществляются с помощью текстовых сообщений по мобильному телефону. Мобильные технологии дают возможность расширить доступ к более широкому кругу населения, а обмен текстовыми сообщениями может обеспечить персонализированную поддержку в отказе от употребления табака эффективным и экономичным способом. Индивидуальные специализированные подходы Интенсивная поведенческая поддержка Поведенческая поддержка означает несколько сеансов индивидуального или группового консультирования, направленных на то, чтобы помочь людям отказаться от употребления табака. Она включает в себя всю помощь в прекращении курения, которая дает информацию об употреблении табака и отказе от него, а также предоставляет поддержку и ресурсы для развития навыков и методов изменения поведения. Клиники для желающих бросить курить Во многих странах существуют клиники, специализирующиеся на услугах по отказу от употребления табака. Эти клиники предлагают интенсивную поведенческую поддержку и, в соответствующих случаях, лекарственные препараты или консультации по обеспечению лекарственными препаратами, предоставляемые специально обученными практикующими врачами. Никотинзаместительная терапия (НЗТ) Препараты для НЗТ выпускаются в нескольких формах, включая жевательную резинку, пастилки, пластыри, ингаляторы и назальный спрей. Эти средства для прекращения курения уменьшают тягу к никотину и облегчают симптомы отмены, обеспечивая поступление в организм низкой контролируемой дозы никотина без токсичных веществ, содержащихся в сигаретах. Дозы препаратов для НЗТ со временем постепенно снижают, чтобы помочь потребителю табака преодолеть зависимость от никотина, привыкнув к постепенно уменьшающейся дозе. Безникотиновая фармакотерапия Эту терапию проводят такими препаратами, как бупропион, варениклин и цитизин. Эти препараты уменьшают тягу к никотину и облегчают симптомы отмены, а также уменьшают приятный эффект от использования сигарет и других табачных изделий. ВИДЫ МЕРОПРИЯТИЙ, НАПРАВЛЕННЫХ НА ПРЕКРАЩЕНИЕ УПОТРЕБЛЕНИЯ ТАБАКА П О ВЕ Д ЕН ЧЕ СК И Е М ЕР Ы Ф А РМ А К О Л О ГИ ЧЕ СК И Е М ЕР Ы бросить курить без посторонней помощи (30). Этот показатель можно увеличить еще больше, если телефонная линия для бросающих курить будет «инициативной», и консультанты будут самостоятельно звонить людям, намеревающимся отказаться от курения. С появлением и распространением технологий мобильной связи люди, которые хотят бросить курить, теперь могут быть доступны не только по обычному телефону, но и с помощью текстовых сообщений. Важным достижением последних лет стали мероприятия по прекращению курения с использованием мобильной связи, которые оказались очень многообещающими. Использование текстовых сообщений может увеличить абсолютную частоту отказа от курения на 4% (31). 38 39ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД УВЕЛИЧЕНИЕ ДОЛИ ЛЮДЕЙ, КОТОРЫЕ ВОЗДЕРЖИВАЮТСЯ ОТ КУРЕНИЯ В ТЕЧЕНИЕ 6 МЕСЯЦЕВ И БОЛЕЕ В РЕЗУЛЬТАТЕ ПРИМЕНЕНИЯ ОТДЕЛЬНЫХ МЕР Самопомощь с использованием печатных материалов Краткая консультация врача Индивидуальная поведенческая поддержка Инициативная поддержка по телефону Автоматический обмен текстовыми сообщениями 0 2 4 6 8 10 12 18 20 14 16 А бс ол ю тн ое у ве ли че ни е до ли л ю де й, бр ос ив ш их к ур ит ь (в п ро це нт ах ) b Один препарат для НЗТ Цитизин Бупропион Нотриптилин Комбинированная НЗТ Варениклин 0 2 4 6 8 10 12 14 16 18 20 А бс ол ю тн ое у ве ли че ни е до ли л ю де й, бр ос ив ш их к ур ит ь (в п ро це нт ах ) b Поведенческие мерыa Фармакологические мерыa Источник: West и соавт. (33) a Каждый столбец представляет результаты метаанализа, и убедительность фактических данных, связанных с каждым исследованием, будет варьироваться. b Это «прогнозируемое увеличение периода воздержания в течение 6–12 месяцев в процентах по сравнению с отсутствием мер». Авторы скорректировали опубликованное процентное увеличение воздержания от употребления табака в течение 6–12 месяцев, чтобы обеспечить прямое сравнение влияния каждой меры в тех случаях, когда в метаанализах не использовался элемент сопоставления, эквивалентный «отсутствию меры». Оценки основывались на опубликованной эффективности сравниваемых мер на основе консенсуса. Меры по прекращению употребления табака, которые действуют наряду с другими мерами по борьбе против табака, Бразилия и США При совместном осуществлении меры борьбы против табака могут действовать синергетически, повышая эффективность каждой отдельной меры. Например, когда в начале 2009 года Соединенные Штаты повысили федеральный налог на сигареты на 0,62 доллара США, количество звонков на телефонную линию для бросающих курить почти утроилось — со 171 570 звонков в январе-мае 2007 года до 533 508 звонков за тот же период в 2009 году. А когда Бразилия стала первой крупной страной, включившей номер своей национальной телефонной службы помощи для бросающих курить в графические предупреждения о вреде для здоровья на упаковках сигарет, на эту линию поступило беспрецедентное количество звонков — до 6 миллионов в первый год, и это больше, чем количество звонков на все остальные линии для бросающих курить во всех странах мира на тот период (35). Фармакологические меры Фармакологические меры, направленные на прекращение курения, включают никотинзаместительную терапию (НЗТ), а также препараты, которые не содержат никотина, но применяются для облегчения симптомов отмены употребления табака. Оба вида терапии являются эффективными вспомогательными средствами, помогающими людям бросить курить. Эффективность фармакотерапии, как правило, высока, и по сравнению с людьми, которые ее не используют, абсолютное увеличение частоты отказа от курения может варьировать от 6% при применении одного вида НЗТ до почти 15% при использовании варениклина. Комбинирование нескольких видов НЗТ (пластырей и форм с более быстрым действием) также может повысить эффективность НЗТ (см. «Комбинированная НЗТ» на диаграмме). Как поведенческая поддержка отказа от курения, так и фармакотерапия эффективны в том, чтобы помочь людям отказаться от употребления табака. Однако сочетание поведенческих и фармакотерапевтических мер является более эффективным и может удвоить шансы на успешный отказ от курения (33). Механизмы развития поддержки отказа от употребления табака Осуществление мер по прекращению употребления табака наряду с другими стратегиями борьбы против табака максимально усиливает их воздействие Поддержка прекращения употребления табака имеет оптимальный эффект, если она осуществляется в сочетании с другими стратегиями борьбы против табака, направленными на сокращение спроса, такими как повышение налогов на табачные изделия, создание среды, свободной от табачного дыма, запрет на рекламу, стимулирование продажи и спонсорство табачных изделий, печать крупных наглядных предупредительных надписей о вреде для здоровья на пачках сигарет и проведение антитабачных кампаний в средствах массовой информации. В свою очередь, эти меры борьбы против табака способствуют прекращению его употребления, поощряя отказ от курения и создавая благоприятные для этого условия. Хорошим примером совместных усилий является указание адреса местного портала и/или телефонного номера программы mCessation или номера телефонной линии для бросающих курить на упаковках сигарет и табака, а также при проведении антитабачных кампаний в средствах массовой информации, что может значительно повысить спрос на услуги по прекращению употребления табака (36). Использование существующей инфраструктуры для развития поддержки в отказе от употребления табака является практически осуществимой и доступной в ценовом отношении задачей Включение кратких консультаций в существующие системы первичной медико-санитарной помощи является одним из первых шагов, которые страны могут предпринять для развития поддержки в отказе от употребления табака. Руководящие принципы Статьи 14 РКБТ ВОЗ рекомендуют странам применять поэтапный подход к развитию и укреплению национальных программ по прекращению употребления табака как можно быстрее и с наименьшими затратами (37). Бо́льшая часть необходимой инфраструктуры для продвижения мер по прекращению употребления табака, таких как система первичной медико-санитарной помощи, уже существует в большинстве стран, что делает такое продвижение не только осуществимым, но и доступным в ценовом отношении. Поэтому каждая страна может использовать свои существующие системы и ресурсы, для обеспечения того, чтобы потребители табака, по крайней мере, получали краткие консультации. Каждая страна может использовать свои существующие системы и ресурсы, для обеспечения того, чтобы потребители табака, по крайней мере, получали краткие консультации, которые могут помочь мотивировать и поддержать успешные попытки бросить курить. Использование мобильного сервиса по отказу от курения (mCessation) демонстрирует огромные перспективы в Индии В 2015 году сотрудничество между ВОЗ и инициативой Международного союза электросвязи «Будь здоровым, будь мобильным», Министерством здравоохранения и благополучия семьи Индии и Министерством связи и информационных технологий привело к разработке программы «mCessation» на основе коротких текстовых сообщений под названием QuitNow, которая поддерживает и побуждает потребителей табака бросить курить. Чтобы оценить эту инициативу, в общей сложности 12 502 подписчика QuitNow были опрошены по телефону в течение 4–6 месяцев после регистрации. Из тех участников, которые когда- либо употребляли табак, 19,1% сообщили, что воздерживались от его употребления в течение предшествующих 30 дней. Необходимы дальнейшие исследования, чтобы лучше понять воздействие программы mCessation на курильщиков в Индии, но предварительные результаты показывают, что она имеет большой потенциал для охвата людей, нуждающихся в поддержке, чтобы бросить курить (31). 40 41ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ПОЭТАПНЫЙ ПОДХОД К РАЗРАБОТКЕ И УКРЕПЛЕНИЮ НАЦИОНАЛЬНЫХ СИСТЕМ СОДЕЙСТВИЯ ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ШАГ 3 Лекарственные препараты Специализированное лечение Повышение вероятности успеха попыток отказа от употребления табака Побуждение к попыткам отказаться от употребления табака ШАГ 1 Обеспечение компонентов системы Решение любых проблем, имеющих отношение к медицинским работникам Интеграция кратких консультаций в существующие системы здравоохранения ШАГ 2 Создание бесплатной инициативной телефонной линии по прекращению курения и/или мобильного сервиса по отказу от курения mCessation Включение кратких консультаций в существующие программы здравоохранения может ежегодно охватить более 80% всех потребителей табака в стране, если эти консультации будут предоставляться регулярно и широко в рамках всей системы здравоохранения (38). Меры по прекращению употребления табака должны быть интегрированы в любые существующие программы здравоохранения в области первичной медико-санитарной помощи, когда это возможно, а также в программы, ориентированные на конкретные заболевания и отдельные группы населения, такие как национальные программы борьбы с туберкулезом (ТБ) (39), программы по НИЗ, программы по гигиене полости рта (40), программы борьбы с ВИЧ/СПИДом, программы охраны психического здоровья и программы, направленные на обеспечение здоровья женщин, детей и подростков. В частности, во всем мире наблюдается серьезное стремление интегрировать услуги по прекращению курения в программы борьбы с туберкулезом и в программы сексуального и репродуктивного здоровья. Обе эти программы охватывают группы населения, подвергающиеся особому риску от вредного воздействия табака, и предоставляют возможность решить проблему табачной зависимости, когда люди вступают (в принципе редко) в контакт с системой здравоохранения. МИНИМАЛЬНЫЕ РАСШИРЕННЫЕ ВСЕСТОРОННИЕ Краткие консультации, интегрированные в услуги первичной медико-санитарной помощи Краткие консультации, интегрированные в услуги первичной медико-санитарной и стационарной помощи Краткие консультации, интегрированные в услуги первичной медико-санитарной, стационарной и специализированной помощи Телефонная линия для бросающих курить: предоставляется бесплатная телефонная линия по прекращению курения Телефонная линия для бросающих курить: предоставляется бесплатная телефонная линия по прекращению курения Программа mCessation: обмен текстовыми сообщениями Программа mCessation: обмен текстовыми сообщениями Специализированные услуги по лечению табачной зависимости: поведенческое консультирование и/или медикаментозное лечение ПРИМЕРЫ МИНИМАЛЬНЫХ, РАСШИРЕННЫХ И ВСЕСТОРОННИХ МЕР ПО ПРЕКРАЩЕНИЮ КУРЕНИЯa a Во всех странах должны предоставляться как минимум краткие консультации. После того, как они будут организованы должным образом, страны могут применять расширенные и всесторонние меры при условии наличия ресурсов. Both behavioural cessation support and pharmacotherapies are effective in helping people to quit tobacco use. Combining Примеры мероприятий по отказу от употребления табака, связанных с программами первичной медико-санитарной помощи Употребление табака и туберкулез Табакокурение увеличивает вероятность заражения, развития и смерти от туберкулезной инфекции. В 2013 году Всемирная ассамблея здравоохранения приняла резолюцию об утверждении Стратегии ликвидации туберкулеза. Стратегия основана на трех основных принципах, один из которых предусматривает интегрированную, ориентированную на нужды пациента помощь и профилактику. Это обеспечивает удобную политическую платформу для согласования усилий по борьбе одновременно с двумя глобальными эпидемиями: табачной и туберкулеза. Региональный план ответных действий Юго-Восточной Азии по интеграции мер борьбы с туберкулезом и табаком на 2017–2021 годы (41) призван помочь государствам-членам внедрить экономически эффективные услуги по прекращению курения с помощью программ борьбы с туберкулезом и скрининга потребителей табака на туберкулез. Все 11 стран региона Юго-Восточной Азии имеют национальные программы борьбы с туберкулезом, интегрированные в системы оказания первичной медико-санитарной помощи, к которым можно добавить компонент услуг по прекращению курения. Пилотные исследования, включающие предоставление кратких консультаций по прекращению употребления табака больным туберкулезом, которые были проведены в Бангладеш, Индии и Индонезии, продемонстрировали, что эта мера может быть эффективной. С тех пор Индия разработала Совместную рамочную программу борьбы с туберкулезом и табаком и осуществляет ее в рамках своих национальных программ борьбы с туберкулезом и табаком. Употребление табака и репродуктивное здоровье Употребление табака во время беременности увеличивает риск развития большого числа осложнений беременности, включая преждевременные роды и самопроизвольный аборт, а также другие отдаленные риски для здоровья как матери, так и будущего ребенка. Успешное лечение употребления табака и зависимости от него может оказать существенное влияние на исходы, связанные с беременностью, и текущие показатели здоровья в целом. Интеграция услуг по прекращению употребления табака в программы репродуктивного здоровья настоятельно рекомендуется в Рекомендациях ВОЗ по профилактике и контролю потребления табака и пассивного курения при беременности (42). В этих рекомендациях говорится, что медицинские работники должны в обязательном порядке предлагать консультации женщинам, употребляющим табак или недавно отказавшимся от этой привычки, а также предоставлять информацию будущим матерям и, по возможности, их партнерам и другим членам их семей о вреде вторичного табачного дыма. Странам также следует рассмотреть возможность использования существующей инфраструктуры для оказания широкой и интенсивной поведенческой поддержки потребителям табака. Во многих странах существуют телефонные контактные центры, горячие линии по вопросам злоупотребления психоактивными веществами или другим вопросам, связанным со здоровьем, которые могут быть расширены для предоставления телефонных услуг по прекращению курения. Предоставление всесторонней поддержки в отказе от употребления табака и лечении табачной зависимости при наличии необходимых ресурсов Стоимость и эффективность различных подходов к борьбе с табакокурением различаются, и поэтому ценовая доступность разных подходов варьируется в странах с низким, средним и высоким уровнями дохода. В целом, почти все поведенческие меры на уровне всего населения являются доступными по цене во всех странах, в то время как интенсивная индивидуальная терапия доступна в ценовом отношении для стран со средним и высоким уровнями дохода (33). Если позволяют ресурсы, страны должны оказывать потребителям табака поддержку наивысшего уровня для содействия успешной попытке бросить курить. Страны могут применять поэтапный подход к развитию своих систем поддержки отказа от употребления табака. Сочетание поведенческих и фармакологических мер является наиболее эффективным способом отказаться от курения, но использование тех или иных мер также зависит от предпочтений людей, которые, вероятно, будут различаться в разных социальных и культурных условиях. Потребители табака могут предпочесть использование нескольких мер по отказу от его употребления, включая использование материалов по санитарному просвещению, консультации медицинских работников, консультирование (индивидуальное, групповое или по телефону), фармакологическую терапию и другие услуги по прекращению употребления табака, оказываемые с помощью текстовых сообщений или онлайн-инструментов (43, 44). Предоставление как можно чаще разнообразных вариантов поддержки в отказе от курения также имеет важное значение для обеспечения максимального охвата и эффективности. 42 43ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Меры по прекращению употребления табака: проблемы и решения Около 30% населения мира имеет доступ к надлежащим услугам по прекращению употребления табака Обеспечение того, чтобы меры по прекращению курения достигали людей, которые в них нуждаются, является серьезной проблемой. В настоящее время около 30% населения мира имеет доступ к надлежащим услугам по прекращению употребления табака (16). Недавнее исследование с использованием данных Глобального опроса взрослого населения о потреблении табака (GATS) из стран с низким и средним уровнями дохода показывает, что менее 50% курильщиков, которые общались с медицинским работником в течение предыдущих 12 месяцев, прошли скрининг на употребление табака или им было рекомендовано бросить курить (45). Этот факт говорит об упущенной возможности охватить большое число потребителей табака. Степень воздействия той или иной меры во многом зависит как от ее эффективности, так и от охвата. Таким образом, поиск практических способов охвата как можно большего числа потребителей табака является ключом к достижению того воздействия, которое поддержка в отказе от табака потенциально может оказать на сокращение распространенности его употребления в стране. количество курильщиков звонить на телефонную линию по прекращению курения для получения направленной на это помощи (47, 48). Следует лучше осознавать действенность и экономическую эффективность программ по прекращению употребления табака Меры политики по борьбе против табака, как правило, весьма эффективны с точки зрения затрат. Такие меры, как повышение налогов на табак, могут оказывать большое воздействие при относительно небольших сопутствующих расходах. Для сравнения, программы отказа от употребления табака несут такие затраты, как время, необходимое персоналу для предоставления кратких консультаций; выделение финансовых средств на НЗТ и лекарственные препараты; и наем консультантов для телефонных линий по прекращению курения. Однако программы по прекращению употребления табака являются весьма эффективными с экономической точки зрения по сравнению с другими мероприятиями систем здравоохранения и клиническими вмешательствами. Совокупная экономическая эффективность использования телефонных линий для бросающих курить и программ проведения кратких консультаций сопоставима с экономической эффективностью скрининга на рак молочной железы (49). МЕРА СРЕДНЯЯ ЭКОНОМИЧЕСКАЯ ЭФФЕКТИВНОСТЬ В СТРАНАХ С НИЗКИМ И НИЖЕ СРЕДНЕГО УРОВНЯМИ ДОХОДА СРЕДНЯЯ ЭКОНОМИЧЕСКАЯ ЭФФЕКТИВНОСТЬ В СТРАНАХ С ВЫСОКИМ И ВЫШЕ СРЕДНЕГО УРОВНЯМИ ДОХОДА Обеспечение в масштабах всей страны оплачиваемой и эффективной поддержки в отказе от употребления табака (включая краткие консультации, национальную бесплатную телефонную линию по прекращению курения) всем тем, кто хочет бросить курить, с охватом 95% из них Очень высокая Высокая Скрининг с помощью маммографии (один раз в 2 года для женщин в возрасте 50-69 лет), сопряженный со своевременной диагностикой патологии, стадированием заболевания, хирургическим лечением, проведением или отсутствием системной терапии (эндокринная терапия или химиотерапия) и устранением токсических эффектов, вызванных лечением Очень высокая Высокая Меры по прекращению употребления табака должны учитывать особенности, характерные для уязвимых групп населения Системы поддержки прекращения употребления табака более эффективны, если они учитывают различные социальные нормы, влияющие на потребление табака, а также трудности, связанные с отказом от его употребления. Социальный статус потребителей табака, такой как пол, возраст, состояние психического здоровья, язык и культура, может сильно повлиять на индивидуальный опыт употребления табака, включая отказ от курения. Например, данные, полученные в ходе исследований эффективности и действенности различных мер, свидетельствуют о том, что женщинам, возможно, труднее добиться длительного воздержания от употребления табака, чем мужчинам. Понимание многих факторов, которые взаимодействуют с полом человека (включая психологические, биологические, фармакологические, социальные, экологические и культурные факторы), и того, как они связаны с отказом от курения, вероятно, поможет разработать более эффективные меры по прекращению курения, направленные на устранение этих гендерных различий (50). Есть также очевидные случаи, когда отсутствие внимания к конкретным социальным факторам и условиям может снизить вероятность отказа от курения. Например, в некоторых странах женщин реже спрашивают об их употреблении табака и реже предлагают краткие консультации в службах первичной медико-санитарной помощи, что может свидетельствовать о предубеждении медицинских работников в отношении женщин и наличии гендерных стереотипов (51). Обеспечение того, чтобы инициативы по прекращению курения были доступны и применимы к женщинам, а также к молодежи, лицам с психическими заболеваниями, этническим меньшинствам, говорящим на разных языках, и другим уязвимым группам населения, может повысить охват и эффективность мер по прекращению употребления табака. Немногие страны проводят постоянный мониторинг и оценку, которые помогают им улучшить качество услуг по прекращению употребления табака Для лиц, принимающих решения, фактические данные являются ключом к обоснованию необходимости осуществления политики борьбы против табака и повышения качества медицинских услуг. Несмотря на наличие большого количества фактических данных об эффективности мер по прекращению употребления табака, лишь немногие страны проводят постоянный мониторинг и оценку, которые помогают им определить качество, эффективность, охват, воздействие и стоимость их услуг по прекращению употребления табака. Отсутствие информации о прогрессе и результатах деятельности служб по прекращению употребления табака на национальном уровне может помешать выявлению приоритетных областей, повышению качества и дальнейшим инвестициям в услуги по отказу от употребления табака. Во многих странах необходимо усилить приверженность осуществлению мер по прекращению употребления табака Во многих странах до сих пор нет национальной стратегии прекращения употребления табака. Лишь в нескольких странах имеется специальный персонал или четко определены бюджеты для программ отказа от курения (52). Системы здравоохранения должны взять на себя основную ответственность за реализацию программ по прекращению употребления табака (37), но поддержка в отказе от его употребления, включенная в услуги первичной медико-санитарной помощи, которая предоставляет потребителям табака ресурсы для отказа от курения, все еще не получила широкого распространения и особенно редко встречается в странах с низким уровнем дохода. ДОЛЯ СТРАН, В КОТОРЫХ ПОДДЕРЖКА ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ОКАЗЫВАЕТСЯ ХОТЯ БЫ В НЕКОТОРЫХ УЧРЕЖДЕНИЯХ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ 0% 9% 15% 53% 80% 17% 53% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 Страны с высоким уровнем дохода Страны со средним уровнем дохода Страны с низким уровнем дохода П ро це нт на я до ля с тр ан , к ом пе нс ир ую щ их з ат ра ты н а по дд ер ж ку п ре кр ащ ен ия у по тр еб ле ни я та ба ка в уч ре ж де ни ях п ер ви чн ой м ед ик о- са ни та рн ой п ом ощ и Многие страны не компенсируют затраты на услуги по прекращению употребления табака для тех, кто их использует Обращение к потребителям табака с просьбой оплатить услуги по прекращению его употребления (например, за телефонные линии по прекращению курения и лекарственные препараты) оказалось серьезным препятствием для обращения за такими услугами даже в странах с высоким уровнем дохода. Хотя в большинстве стран НЗТ предоставляется без медицинского осмотра или выписки рецепта, стоимость покупки может ограничить доступ к такой терапии, особенно для людей с низкими доходами (46). Не все механизмы компенсации затрат или страхования покрывают стоимость НЗТ, и даже когда это происходит, существуют некоторые препятствия там, где эти механизмы действительно применяются. Например, может случиться так, что рецепты, выписанные некоторыми медицинскими работниками, например стоматологами (которые могут быть обучены проведению кратких консультаций), не подлежат возмещению. Крайне важно, чтобы страны компенсировали затраты на поддержку в отказе от употребления табака для своих потребителей. Исследование, проведенное в Нью-Йорке, показывает, что предложение бесплатной НЗТ может увеличить частоту отказа от курения и действовать как экономически эффективная маркетинговая стратегия, мотивирующая большое МЕРЫ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ЯВЛЯЮТСЯ ЭКОНОМИЧЕСКИ ЭФФЕКТИВНЫМИ 44 45ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Электронные сигареты и другие изделия, продаваемые как «средства для прекращения курения» В последние годы табачная промышленность (и другие участники коммерческой деятельности, не связанной с табаком, такие как производители электронных сигарет) представила широкий спектр изделий, большинство из которых имитируют процесс курения, как правило доставляя никотин в организм человека. В настоящее время существует три основные категории этих изделий: Изделия из нагреваемого табака (ИНТ) — это табачные изделия, которые образуют аэрозоли, содержащие никотин и токсичные химические вещества, при нагревании табака или активации устройства, содержащего табак. Эти аэрозоли вдыхаются пользователями во время процесса затягивания или курения с использованием устройства. Они содержат никотин, вызывающий сильное привыкание, а также нетабачные добавки, зачастую ароматизированные. Табак может быть в виде сигарет специальной конструкции (например, «нагреваемые табачные палочки», «нео-стики»), капсул или вставок. Электронные системы доставки никотина (ЭСДН) — это устройства, которые нагревают жидкость для создания аэрозоля, вдыхаемого пользователем. Жидкость содержит никотин (но не табак) и другие химические вещества, которые могут быть опасными для здоровья людей. Электронные системы доставки продуктов, не являющихся никотином (ЭСДПН), похожи на ЭСДН, но нагретый раствор, подаваемый через устройство в виде аэрозоля, обычно не содержит никотина. Эти изделия активно продаются или продвигаются на рынке как более «чистая» замена обычным сигаретам, как средства, помогающие бросить курить, или как изделия «сниженного риска». Они получили широкое распространение на рынках ряда стран по всему миру и представляют собой уникальную проблему для регулирующих органов. Хотя некоторые из этих изделий выделяют меньше токсичных веществ, чем обычные сигареты, они не являются безопасными, и их долгосрочное влияние на здоровье и смертность пока неизвестно. На сегодняшний день нет достаточного количества независимых фактических данных в поддержку использования этих изделий в качестве способа для прекращения употребления табака на уровне всего населения, чтобы помочь людям отказаться от обычного употребления табака. ИНТ содержат табак, и использование этих изделий представляет собой употребление табака, увеличивая тем самым связанное с ним бремя в странах, где они продаются. Кроме того, имеющиеся фактические данные не подтверждают утверждения табачной промышленности о том, что эти изделия менее вредны по сравнению с обычными табачными изделиями (53, 54). Остается большая неопределенность в отношении потенциальной токсичности ЭСДН. Хотя некоторые из них, как было показано, помогают курильщикам при определенных условиях отказаться от обычного курения, научные данные об использовании ЭСДН в качестве НЗТ (55, 56) неубедительны (57–59). Было проведено лишь ограниченное число рандомизированных контрольных исследований и лонгитудинальных исследований, посвященных изучению роли ЭСДН как потенциального средства помощи, предлагаемого населению для прекращения курения, и выводы этих исследований неоднозначны (57, 59). Два обзора, проведенные в 2016 и 2017 годах, показали, что из имеющихся результатов исследований нельзя сделать никаких достоверных выводов (57, 59). Это согласуется с выводом Национальной академии наук в ее обзоре фактических данных по ЭСДН за 2018 год (в этом и последующих докладах они называются электронными сигаретами), в котором говорится, что «в целом, есть некоторые доказательства того, что электронные сигареты могут быть эффективным средством содействия прекращению курения» (60). Учитывая недостаток и низкое качество научных данных, невозможно определить, могут ли ЭСДН помочь или, наоборот, помешать большинству курильщиков бросить курить (FCTC/COP7/11). Напротив, рандомизированное контрольное исследование в отношении использования электронных сигарет в сравнении с никотинзаместительной терапией показало, что «электронные сигареты были более эффективным средством для прекращения курения, чем никотинзаместительная терапия, когда оба способа сопровождались поведенческой поддержкой» (61). Однако это исследование имеет ряд ограничений, и любое рассмотрение результатов должно проводиться с осторожностью. Например, хотя те, кому были назначены электронные сигареты, чаще воздерживались от использования обычных сигарет по сравнению с теми, кому была назначена НЗТ, 80% пользователей электронных сигарет продолжали их использовать через год после начала исследования. И это по сравнению с очень небольшим процентом людей, получавших НЗТ, которые продолжали ее использовать. В большинстве стран, где доступны электронные сигареты, бо́льшая часть пользователей продолжают их использовать одновременно с обычными сигаретами, что практически не дает положительного результата в отношении уменьшения рисков и последствий для здоровья (62). В то же время в некоторых обзорах также высказывается предположение о том, что использование электронных сигарет на самом деле может препятствовать прекращению курения (63). Кроме того, затрудняя отказ от курения, инновационные и новые табачные и никотиновые изделия все чаще используются теми, кто никогда не употреблял табак (64). Таким образом, эти изделия играют важную роль в расширении прослойки потребителей никотина с высоким риском развития у них табачной зависимости, особенно среди детей и подростков. Ложная информация, распространяемая табачной промышленностью об электронных сигаретах, в настоящее время является реальной угрозой Научные данные о том, что электронные сигареты служат средством для прекращения курения, неубедительны, и нет ясности относительно того, влияют ли эти изделия каким-либо образом на отказ от курения. Существуют также реальные опасения по поводу риска, который они несут для некурящих лиц, начинающих их использовать, особенно для молодых людей. В отличие от испытанных никотиновых и безникотиновых фармакотерапевтических препаратов, которые, как известно, помогают людям отказаться от употребления табака, ВОЗ не одобряет использование электронных сигарет как средства для прекращения курения. Поскольку ЭСДН все чаще появляются на рынке, тщательный мониторинг показателей прекращения курения приобретает крайне важное значение. Возможность вмешательства табачной промышленности в усилия по прекращению употребления табака путем распространения ложной информации о потенциальных преимуществах этих изделий, которые позиционируются как альтернатива использованию обычных табачных изделий, но в большинстве случаев их дополняют, представляет собой существующую реальную угрозу. Этот вопрос и другие проблемы, связанные с ЭСДН и ИНТ, обсуждаются более подробно в следующих разделах настоящего доклада. Максимизация усилий по прекращению курения Правительствам следует взять на себя более серьезные политические и финансовые обязательства по содействию прекращению употребления табака Осуществление мер по прекращению употребления табака может помочь существенно сократить распространенность его употребления и спасти жизни людей (65, 66). По оценкам, если бы меры по прекращению употребления табака были реализованы на самом высоком уровне в 14 странах в период с 2007 по 2014 год, можно было бы спасти 1,5 миллиона человеческих жизней (19). Для достижения связанных с табаком глобальных целей в области борьбы с НИЗ и реализации ЦУР 46 47ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД правительствам необходимо рассматривать отказ от употребления табака в качестве важного приоритета для общественного здравоохранения и инвестировать в него соответствующие средства. Статья 14 РКБТ ВОЗ предусматривает план более решительной поддержки прекращения употребления табака. Основные рекомендации включают следующие действия. Содействие поддержке в отказе от употребления табака в рамках всесторонней программы борьбы против табака Программы прекращения употребления табака более эффективны, когда они являются частью всесторонней программы борьбы против табака. Странам следует ускорить полное осуществление РКБТ ВОЗ, включая положения Статьи 14, касающиеся прекращения употребления табака и лечения табачной зависимости. Признание поддержки в отказе от употребления табака в качестве важнейшего компонента всеобщего охвата услугами здравоохранения Помощь потребителям табака в отказе от курения является одной из наиболее экономически эффективных профилактических услуг в системе первичной медико-санитарной помощи. ВОЗ рекомендует отказ от употребления табака в качестве одного из основных мероприятий в области неинфекционных заболеваний для системы первичной медико-санитарной помощи в условиях ограниченных ресурсов (PEN ВОЗ: https://www.who.int/ncds/ management/pen_tools/en/) из-за его важности в профилактике и лечении НИЗ, таких как сердечно-сосудистые заболевания, рак, хронические респираторные заболевания и диабет. Страны должны включить поддержку прекращения употребления табака в свой пакет мероприятий по всеобщему охвату услугами здравоохранения, с тем чтобы предоставлять ориентированные на нужды людей медицинские услуги в рамках первичной медико-санитарной помощи. Как минимум, страны должны обеспечить подготовку медицинских работников для предоставления кратких консультаций в рамках всех существующих программ здравоохранения в системе первичной медико-санитарной помощи и сделать обязательным регистрацию факта употребления табака в медицинских картах пациентов. Подготовка в области прекращения употребления табака должна быть частью всех программ профессиональной подготовки медицинских работников и частью обязательной учебной программы для всех медицинских профессий. Обучить медицинских работников регулярному предоставлению кратких консультаций можно с помощью однодневного семинара или даже с помощью онлайн-курса обучения. Чтобы помочь странам в их усилиях по интеграции кратких консультаций в систему первичной медико- санитарной помощи, ВОЗ разработала комплект учебно-методических материалов Укрепление систем здравоохранения для лечения табачной зависимости в учреждениях первичной медико-санитарной помощи (67) и электронный курс дистанционного обучения — Курс для работников служб первичной медико-санитарной помощи: кратковременные антитабачные мероприятия (доступен по ссылке: https://www.who.int/ tobacco/quitting/training-for-primary-care-sizes/ en/). Эти материалы находятся в свободном доступе. Целевое ассигнование табачных налогов на прекращение употребления табака: инновационная программа в Таиланде Финансируемый за счет поступлений от акцизов на табак и алкоголь, Тайский фонд укрепления здоровья (ThaiHealth) поддержал несколько проектов по прекращению курения. Например, с 2009 года он постоянно финансирует Национальную телефонную линию по прекращению курения, обслуживающую до 22 000 курильщиков в год с показателем успешных попыток отказа от курения 33% (70). С 2016 года фонд финансирует Министерство здравоохранения для повышения качества услуг по прекращению курения во всех больницах. ThaiHealth совместно с Министерством здравоохранения и всеми другими заинтересованными сторонами также организовал и запустил проект под названием «Три миллиона бросивших курить за три года». Этот проект, начавшийся в июне 2016 года и завершившийся в конце мая 2019 года, привлек 1 миллион волонтеров Министерства здравоохранения из сельской местности в систему здравоохранения, чтобы помочь одному курильщику в год успешно бросить курить как минимум на 6 месяцев (попросив людей полностью отказаться от употребления табака, используя местные ресурсы, и/или направив их за поддержкой в службы по прекращению употребления табака Министерства здравоохранения, если это было необходимо). В случае успеха, этот проект ежегодно заставит 1 миллион человек бросить курить, что в общей сложности составит 3 миллиона бросивших курить за 3 года. В ноябре 2018 года министр здравоохранения объявил, что этот проект станет одним из показателей, используемых для оценки эффективности работы всех высших должностных лиц Министерства, и это заявление побудило участников проекта удвоить свои усилия. В январе 2019 года Министерство объявило, что около 1,7 миллиона курильщиков начали отказываться от употребления табака в рамках этой программы. Создание устойчивого источника финансирования поддержки отказа от употребления табака Укрепление или создание национальной инфраструктуры для активизации и предоставления поддержки и услуг по прекращению употребления табака требует как финансовых, так и технических ресурсов, поэтому крайне важно определить устойчивый источник финансирования. Странам следует рассмотреть вопрос о том, чтобы переложить расходы по поддержке прекращения употребления табака на табачную промышленность и других розничных продавцов с помощью таких мер, как специальные налоги на табачные изделия; лицензионные сборы за производство и/или импорт табачных изделий; лицензии на продажу табачных изделий для оптовых и розничных продавцов; а также сборы с табачной промышленности и розничных продавцов за несоблюдение установленных требований. Предложение определенного уровня компенсации или финансового стимулирования может оказать существенное влияние как на обращение за лечением для прекращения курения, так и на вероятность того, что пациенты будут придерживаться этого лечения (68). Меры, снижающие стоимость лечения для курильщиков, не только увеличивают число людей, которые пытаются бросить курить, но и повышают вероятность их успеха в прекращении курения (69). Содействие развитию государственно- частного партнерства и вовлечение различных заинтересованных сторон Крайне важно, чтобы правительства и неправительственные организации работали в тесном сотрудничестве для ускорения реализации мер по прекращению употребления табака и уменьшению причиняемого им вреда. Государственно- частные партнерства (которые исключают табачную промышленность и финансируемые ею фонды) могли бы расширить масштабы финансирования и услуг по прекращению употребления табака, предлагаемых в странах. Например, многие национальные или региональные телефонные линии по прекращению курения субсидируются за счет сочетания государственного и негосударственного финансирования. Частные страховые компании и работодатели также могут предложить меры материального поощрения (например, снижение страховых взносов или предоставление дополнительных выплат и льгот персоналу), чтобы помочь мотивировать успешное использование сотрудниками услуг по прекращению курения, учитывая сокращение затрат на медицинское обслуживание и повышение производительности труда, которых можно ожидать после прекращения употребления табака. Установление приоритетности подходов к прекращению употребления табака на уровне всего населения Ресурсы ограничены. Для того чтобы меры по прекращению употребления табака охватили как можно больше его потребителей при минимально допустимых затратах и оказали наибольшее воздействие, правительствам следует уделять приоритетное внимание подходам к прекращению употребления табака в масштабах всего населения и рассмотреть возможность принятия трех подходов, охватывающих все население, рекомендованных в Глобальном плане действий ВОЗ по НИЗ на 2013–2020 годы: интеграция кратких консультаций в систему первичной медико-санитарной помощи, предоставление услуг национальной бесплатной телефонной линии для бросающих курить и обеспечение доступности поддержки mCessation. Использование инновационных подходов для расширения охвата мероприятиями по прекращению употребления табака Важным аспектом ЦУР 9, касающейся индустриализации, инноваций и инфраструктуры, является признанная необходимость того, чтобы люди имели 48 49ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД существенно повлиять на сокращение распространенности употребления табака во всем мире. Разработка эффективных стратегий передачи информации Кампании по повышению информированности населения должны разрабатываться таким образом, чтобы разъяснять действенность и экономическую эффективность мер по прекращению употребления табака широким слоям населения и сообществу по борьбе против табака. Важно также наладить эффективную систему коммуникации, которая информирует людей о различных доступных видах поддержки, а также о том, где к ней можно получить доступ. Согласованные заявления медицинских работников оказывают большое влияние. Кампании должны быть тщательно продуманы, чтобы ориентироваться на конкретную аудиторию в различных условиях, и чтобы они максимально углубили понимание и получили поддержку населения, необходимую для достижения успеха. Мониторинг и оценка всех стратегий и программ прекращения употребления табака Мониторинг и оценка имеют важное значение для обеспечения использования наилучших средств для разработки основанных на фактических данных и экономически эффективных мер по прекращению употребления табака, которые помогают его потребителям бросить курить. Способность извлекать уроки из опыта разработки и реализации программ по прекращению употребления табака затрудняется из-за недостатка и низкого качества данных, особенно в странах с низким и средним уровнями дохода. Странам следует продолжать осуществлять мониторинг и оценку реализуемых стратегий и программ по прекращению употребления табака, в том числе промежуточных и итоговых показателей, с целью наблюдения за тенденциями и воздействием с течением времени. Налаживание тесного сотрудничества с академическими институтами, национальными статистическими управлениями, неправительственными организациями и другими заинтересованными сторонами поможет разработать надлежащие методы мониторинга и оценки, а также предусмотреть использование более эффективных и специализированных услуг. Соблюдение осторожности в отношении инновационных и новых табачных и никотиносодержащих изделий Политические действия и меры в области здравоохранения должны основываться на надежных научных данных. Если данных о потенциальном вреде новых изделий недостаточно, страны должны проявлять осторожность, обеспечивая, чтобы их законодательство отвечало современным требованиям и в достаточной мере защищало здоровье своих граждан. надлежащий доступ к информации и услугам. Необходимо использовать новейшие технологии для обеспечения доступа населения к информации об опасностях употребления табака через популярные форумы, такие как социальные сети; кроме того, следует продолжать дальнейшую разработку мер с использованием мобильных телефонов и других цифровых платформ. Следует также поощрять исследования и разработки в инновационных направлениях для использования таких достижений, как мобильные технологии и искусственный интеллект, в мероприятиях по прекращению курения. В настоящее время мы знаем, какие меры реально работают, но они еще не охватывают достаточное количество потребителей табака. Расширение охвата и доступа к услугам по прекращению курения, например, с помощью мобильного здравоохранения (mHealth) и носимых электронных устройств, может помочь Крайне важно, чтобы правительства и неправительственные организации работали в тесном сотрудничестве для ускорения реализации мер по прекращению употребления табака и уменьшению причиняемого им вреда. 50 51ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Изделия из нагреваемого табака Изделия из нагреваемого табака содержат табак Изделия из нагреваемого табака (ИНТ) — это табачные изделия, которые образуют аэрозоли, содержащие никотин и токсичные химические вещества, при нагревании табака или активации устройства, содержащего табак. Эти аэрозоли вдыхаются потребителями во время процесса затягивания или курения при использовании устройства. Они содержат никотин, вызывающий сильное привыкание, а также нетабачные добавки, зачастую ароматизированные. Табак может быть в виде сигарет специальной конструкции (например, «нагреваемые табачные палочки», «нео-стики»), капсул или вставок. ИНТ отличаются не только от обычных сигарет, но и от электронных систем доставки никотина (ЭСДН, некоторые из которых называются электронными сигаретами), поскольку ЭСДН содержат не табак, а раствор никотина. Однако эти отличия становится все труднее определить. Сегодня наблюдается увеличение количества новых «гибридных» табачных изделий, содержащих как раствор никотина, так и табак. Примеры ИНТ включают IQOS производства Philip Morris International (PMI), Ploom TECH производства Japan Tobacco International (JTI), Glo производства British American Tobacco (BAT) и PAX производства PAX Labs. Фактические данные в отношении ИНТ являются неубедительными В то время как технология ИНТ существует с 1980-х годов, новые поколения изделий, ставших популярными за последние 5 лет, имеют другие особенности и механизмы действия по сравнению с более ранними версиями. Это означает, что хотя исследования ИНТ проводились с момента их появления, выводы в отношении более ранних изделий не могут быть применены к более поздним. Учитывая, что продукты нового поколения не присутствуют на рынке достаточно долгое время, фактических данных об их влиянии на здоровье людей крайне мало. Кроме того, источником большей части существующих научных данных об ИНТ является табачная промышленность, и поэтому их объективность, вероятно, можно поставить под сомнение ввиду возникающего у этой промышленности конфликта интересов. ИНТ следует регулировать как табачные изделия В настоящее время ИНТ доступны более чем в 40 странах. Хотя в некоторых странах они запрещены, существуют значительные различия в том, как они регулируются в других странах. На способность страны контролировать и регулировать использование ИНТ влияют многие факторы, в том числе национальные распорядительные полномочия, возможности обеспечения нормативно-правового регулирования, потенциал страны и вмешательство табачной промышленности. Как и в случае с другими табачными изделиями, меры MPOWER применяются к ИНТ ИНТ являются табачными изделиями. Это означает, что обязательства Сторон по РКБТ ВОЗ применяются к ИНТ точно так же, как они применяются к обычным сигаретам. Меры MPOWER помогают государствам-членам ВОЗ осуществлять статьи РКБТ ВОЗ о сокращении спроса на табак и в равной степени применимы к ИНТ, как и к другим табачным изделиям. Это четко сформулировано в информационном бюллетене ВОЗ, ВОПРОС КРАТКОЕ ИЗЛОЖЕНИЕ ФАКТИЧЕСКИХ ДАННЫХ Содержат ли ИНТ вредные химические вещества? Из имеющихся фактических данных мы знаем, что многие вредные химические вещества, генерируемые ИНТ, аналогичны тем, которые генерируются обычными сигаретами, но, как правило, на более низких уровнях (71, 72). Однако имеются также некоторые фактические данные о том, что в ИНТ присутствуют новые химические вещества, которых нет в выделяемых продуктах обычных сигарет, и которые могут иметь некоторую степень токсичности и приносить связанный с этим вред (53). ИНТ менее вредны, чем сигареты? На сегодняшний день имеющиеся фактические данные свидетельствуют о том, что воздействие на здоровье человека опасных и потенциально опасных химических веществ, содержащихся в этих изделиях, может быть менее сильным по сравнению с обычными сигаретами (73) (но более сильным по сравнению с электронными системами доставки никотина (ЭСДН), см. следующий раздел). Однако имеющиеся данные не говорят о том, что использование этих изделий уменьшат количество заболеваний, связанных с табаком, или что они используются исключительно в качестве заменителей сигарет. Если эти изделия привлекут потребителей, которые ранее не употребляли табак, их общее воздействие на здоровье будет негативным. Можно ли использовать ИНТ в качестве средства для прекращения курения? ИНТ являются табачными изделиями, и поэтому, даже если потребитель табака перейдет от использования обычных сигарет к ИНТ, это не будет означать прекращения употребления табака. Утверждения о том, что курильщики переходят от обычных сигарет к использованию только ИНТ, необоснованны (74). Необходимы дальнейшие независимые исследования для сбора дополнительной информации и обоснования вариантов принимаемых мер. посвященном изделиям из нагреваемого табака, который содержит руководящие указания о том, как следует регулировать эти изделия (75), а также в решении FCTC/ COP8 (22) по инновационным и новым табачным изделиям. Маркетинг ИНТ должен тщательно контролироваться и регулироваться Маркетинг ИНТ является одной из самых серьезных проблем в борьбе против табака. Эти изделия широко рекламируются с использованием заявлений, в которых прямо или косвенно утверждается, что они являются более безопасной и менее токсичной альтернативой обычным сигаретам (53). Производители используют отсутствие четкого консенсуса в отношении конкретных форм вреда, причиняемого ИНТ, чтобы ввести потребителей в заблуждение и уклониться от существующего регулирования, а также избежать введения нормативных требований, распространяющихся на эти изделия. Например, в то время как ИНТ широко продаются как более безопасные альтернативы для курильщиков, производители, как правило, тщательно продумывают свои заявления или предусматривают отказ от ответственности (76). Производители часто заявляют, что аэрозоль, получаемый из ИНТ, содержит меньшее количество вредных компонентов, чем сигаретный дым, и поэтому менее вреден для здоровья (76). Однако такие фразы, как «вероятно, причинят меньше вреда» или «потенциально могут причинить меньший вред», не означают, что это свидетельствует о снижении риска для здоровья. 52 53ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД n ИНТ содержат табак и подлежат регулированию так же, как и табачные изделия. n ИНТ выделяют токсичные продукты, многие из которых аналогичны токсичным веществам, содержащимся в сигаретном дыме. n Пользователи ИНТ подвергаются воздействию токсичных выделяемых продуктов, и окружающие лица также могут подвергаться вторичному воздействию этих токсичных продуктов. n Хотя содержание некоторых токсичных веществ в ИНТ ниже, чем в обычных сигаретах, содержание других веществ выше. Более низкое содержание некоторых токсичных веществ не обязательно означает снижение риска для здоровья. n ИНТ содержат никотин. Никотин вызывает сильное привыкание и наносит вред здоровью, особенно у детей, беременных женщин и подростков. n Долгосрочные последствия использования ИНТ и воздействия выделяемых ими продуктов на здоровье человека остаются неизвестными. В настоящее время нет достаточного количества независимых фактических данных об относительном и абсолютном риске их использования. Необходимы независимые исследования, чтобы определить риск для здоровья, который ИНТ представляют для пользователей и окружающих лиц. Ключевая информация и рекомендации для стран Изделия из нагреваемого табака (ИНТ) являются табачными изделиями. Это означает, что обязательства Сторон по РКБТ ВОЗ применяются к ИНТ точно так же, как они применяются к обычным сигаретам. Большинство маркетологов ИНТ намеренно пытаются позиционировать их как изделия, отличные от сигарет. Их рекламируют как «бездымные», утверждая, что производимые ими аэрозоли не являются дымом, и что ИНТ не образуют смол. Это означает, что они часто продаются как более экологически чистая и социально приемлемая альтернатива сигаретам. Кроме того, ИНТ широко продвигаются как современные, высокотехнологичные и высококачественные престижные изделия с минималистским дизайном, присутствием в крупнейших магазинах и с проведением масштабных рекламных кампаний по выводу на рынок, в которых эти изделия изображаются как привлекательные и безвредные потребительские товары класса люкс. Во всей этой деятельности используются методы социального позиционирования, которые ранее использовались для продажи сигарет и которые особенно эффективны в отношении молодежи. В конечном счете, в соответствии с руководящими указаниями ВОЗ, все формы употребления табака приносят вред, в том числе и ИНТ. Табак токсичен по своей природе и содержит канцерогены, независимо от того, употребляется ли он как курительный или бездымный (75). В целом, учитывая имеющуюся у нас информацию и тот факт, что эти изделия содержат табак, они должны регулироваться как табачные изделия. В соответствии с РКБТ ВОЗ на них должны распространяться те же политические и нормативно-правовые меры, что и на все табачные изделия. 54 55ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Электронные системы доставки никотина Электронные системы доставки никотина отличаются разнообразием и становятся все более доступными Электронные системы доставки никотина (ЭСДН) — это устройства, которые нагревают жидкость для создания аэрозоля, вдыхаемого пользователем. Жидкость содержит никотин (но не табак) и другие химические вещества, которые могут быть опасными для здоровья людей. «ЭСДН» — это всеобъемлющий термин, обозначающий несколько категорий изделий. Наиболее распространенными ЭСДН являются «электронные сигареты», также известные как «вейпы» или «вейп- ручки». Другие категории ЭСДН включают «электронные кальяны», «электронные трубки» и «электронные сигары». Некоторые из изделий напоминают их обычные табачные аналоги: сигареты, сигары, сигариллы, трубки или кальяны; другие имеют более общую форму, похожую на ручки, USB-флешки или простые цилиндры. В этих изделиях также используются различные формы никотина. В последнее время для доставки высоких доз никотина стали использоваться его соли. Разнообразие товарных групп менялось с течением времени и в зависимости от географических и/или демографических рынков. Существуют и другие электронные системы доставки продуктов, не являющихся никотином (ЭСДПН), которые, по сути, представляют собой то же, что и ЭСДН, но используемая в них жидкость обычно не содержит никотина (хотя при тестировании было обнаружено, что многие растворы с «нулевым содержанием никотина» содержат никотин). Данный доклад касается только ЭСДН и не затрагивает ЭСДПН. Примеры ЭСДН включают Juul производства Juul Labs, Vype производства British American Tobacco, Blu производства Imperial Brands. Фактические данные о рисках для здоровья, связанных с использованием ЭСДН, остаются неубедительными ВОЗ тщательно проанализировала и обобщила имеющиеся фактические данные в отношении ЭСДН и пришла к выводу, что имеющиеся на сегодняшний день данные неубедительны. Важно отметить, что ЭСДН представляют собой многообразную группу изделий, содержащих большое разнообразие дозировок никотина, ароматов и выделяемых продуктов. В результате уникальные характеристики конкретного типа электронной системы доставки никотина, такие как химический состав, нагревательный элемент или способ и место ее использования, будут играть важную роль в ее воздействии на здоровье людей. Более надежное определение ВОПРОС КРАТКОЕ ИЗЛОЖЕНИЕ ФАКТИЧЕСКИХ ДАННЫХ Каковы последствия использования ЭСДН в более молодом возрасте? Недавние исследования в Соединенных Штатах Америки (США) и некоторых европейских странах показали заметный рост использования ЭСДН среди молодежи (77). В США в период с 2011 по 2018 год показатель использования электронных сигарет среди молодежи вырос с 1,5% до ошеломляющих 20,8% (78). Молодые люди, использующие ЭСДН, подвергаются воздействию никотина, который может оказывать долгосрочное негативное влияние на развивающийся мозг, и при этом существует риск развития никотиновой зависимости, учитывая, что привычка употребления табачных изделий в основном формируется в подростковом возрасте (79). При этом некоторые источники приводят все больше свидетельств того, что никогда ранее не курившие несовершеннолетние, использующие ЭСДН, имеют по крайней мере в два раза больше шансов начать курить сигареты в более позднем возрасте (80, 81). В чем состоит вред ЭСДН по сравнению с обычными сигаретами? Аэрозоли, образуемые ЭСДН, могут быть менее токсичными, чем сигареты, но фактических данных для количественной оценки точного уровня связанного с ними риска недостаточно (82). Кроме того, на относительный риск, связанный с использованием ЭСДН, будут влиять многие факторы. Например, содержание никотина и других токсичных веществ в нагреваемой жидкости. К каким последствиям для здоровья приводит использование ЭСДН? ЭСДН представляют опасность для здоровья пользователей и окружающих лиц (82). Фактических данных для количественной оценки этой опасности недостаточно, а долгосрочные последствия воздействия токсичных продуктов, выделяемых ЭСДН, неизвестны (77, 82). Помимо рисков, связанных с выделяемыми ЭСДН продуктами, существуют также риски получения физических травм в результате пожаров или взрывов, связанных с устройствами ЭСДН (83). Помогают ли ЭСДН курильщикам отказаться от курения? Как обсуждалось ранее в разделе, посвященном мере MPOWER «О» — «Предложение помощи в целях прекращения употребления табака», научные данные об эффективности ЭСДН в качестве средства для прекращения курения все еще обсуждаются. На сегодняшний день, отчасти из-за разнообразия изделий ЭСДН и низкой достоверности многих исследований, возможность использования ЭСДН в качестве меры вмешательства по прекращению курения на уровне всего населения до конца неясна (57-59). последствий использования ЭСДН потребует тщательного изучения результатов в отношении здоровья больших когорт хорошо охарактеризованных пользователей в течение более длительного периода времени. Потенциальное воздействие ЭСДН на здоровье населения активно обсуждается с момента их появления на потребительских рынках 12–15 лет назад. ЭСДН не безвредны и должны регулироваться Согласно рекомендациям ВОЗ, государства- члены, которые не запретили использование ЭСДН, должны рассмотреть вопрос об их регулировании как вредных для здоровья изделий, а правительства должны принять меры регулирования в отношении ЭСДН, которые, по их мнению, наиболее подходят для их национальных условий. Это может повлечь за собой, например, регулирование ЭСДН как табачных изделий, изделий, имитирующих табак, или как изделий особой категории. Хотя конкретный уровень риска, связанный с ЭСДН, еще окончательно не установлен, они, несомненно, приносят вред и поэтому должны подлежать регулированию. Меры MPOWER могут применяться к ЭСДН Как и любая продукция, которая может нанести вред здоровью, все изделия ЭСДН должны регулироваться, и существующие эффективные инструменты политики, такие как меры MPOWER, могут быть успешно применены к ЭСДН. Руководящие указания, содержащиеся в докладе ВОЗ Конференции Сторон 2014 года (FCTC/COP/6/10 Rev.1), изложены во вставке справа (82). (a) препятствовать рекламе ЭСДН, ориентированной на некурящих, беременных женщин и молодежь, и использованию ЭСДН ими; (b) минимизировать потенциальные риски для здоровья тех, кто использует и не использует ЭСДН; (c) запретить бездоказательные заявления о влиянии ЭСДН на здоровье; и (d) защитить предпринимаемые усилия по борьбе против табака от коммерческих и иных корпоративных интересов табачной промышленности. Регулирование ЭСДН должно: 56 57ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД M Правительствам рекомендуется использовать свои существующие системы надзора за табачными изделиями и их мониторинга для оценки развития ситуации в области использования ЭСДН с разбивкой по таким важным факторам, таким как пол и возраст. P Пользователям ЭСДН следует в юридическом порядке запретить использование ЭСДН в помещениях, особенно там, где курение запрещено, пока не будет доказано, что выдыхаемый пар не представляет вреда для окружающих, и не будут получены обоснованные доказательства того, что это не подрывает политику обеспечения бездымной среды. Это связано с тем, что обоснованным ожиданием со стороны окружающих является не «сокращение риска» по сравнению с воздействием вторичного дыма, а «отсутствие увеличения риска» со стороны какого бы то ни было продукта в воздухе, которым они дышат. O Доказательства использования ЭСДН в качестве потенциальной помощи для прекращения курения все еще обсуждаются. Некоторые фактические данные свидетельствуют о том, что ЭСДН могут помочь отдельным людям отказаться от курения. Однако данные, необходимые для подтверждения возможности использования ЭСДН в качестве средства для прекращения курения в масштабах всего населения, ограничены. Следовательно, ЭСДН не следует пропагандировать как средство помощи в прекращении употребления табака до тех пор, пока не будут собраны достоверные данные по конкретным типам ЭСДН, и медицинское сообщество не сможет прийти к соглашению об эффективности этих конкретных изделий. W Предупреждения о вреде ЭСДН для здоровья должны соответствовать доказанным рискам для здоровья. В этой связи можно было бы рассмотреть возможность использования следующих предупреждений о рисках: потенциальная никотиновая зависимость; потенциальное раздражающее действие на дыхательные пути, глаза, нос и горло; потенциальный риск развития сердечно-сосудистых заболеваний; потенциальные негативные последствия при беременности (вследствие воздействия никотина). E Учитывая, что те же самые рекламные элементы, обеспечивающие привлекательность ЭСДН для взрослых курильщиков, могут сделать их привлекательными для детей и некурящих, следует рассмотреть возможность введения эффективных ограничения на рекламу, стимулирование продажи и спонсорство ЭСДН. Любые формы рекламы, стимулирования продажи и спонсорства ЭСДН должны регулироваться соответствующим государственным органом. Если это не представляется возможным, предпочтительнее применять прямой запрет на рекламу, стимулирование продажи и спонсорство ЭСДН. Дополнительные рекомендации в отношении регулирования рекламы, стимулирования продажи и спонсорства ЭСДН можно найти в документе FCTC/COP/6/10 Rev.1 (82). R Хотя ЭСДН, как правило, менее токсичны, чем обычные сигареты, они все же несут риск для здоровья. Имеющиеся фактические данные свидетельствуют о том, что аэрозоль ЭСДН не является всего лишь «водяным паром», как это часто утверждается в процессе сбыта этих изделий. Использование ЭСНД создают серьезную угрозу для подростков и внутриутробного развития плода. Кроме того, они усиливают воздействие никотина и ряда токсичных веществ на некурящих лиц и окружающих. Поэтому в отношении этих изделий следует применять налогообложение в соответствии с национальными стандартами, чтобы предотвратить их использование, особенно молодыми людьми. Использование ЭСДН может подорвать усилия по борьбе против табака Существует ряд проблем, связанных с регулированием ЭСДН, которые часто упоминаются как «чистые альтернативы», изделия «сниженного вреда» или «сниженного риска» по сравнению с обычными табачными изделиями. Эти утверждения имеют ряд последствий для общественного здравоохранения и борьбы против табака. Например, должностные лица, занимающиеся вопросами общественного здравоохранения, обеспокоены возможностью того, что эти устройства служат «средством приобщения» молодежи к традиционному курению. ЭСДН активно продаются молодым людям за счет использования ароматизаторов и других способов стимулирования продаж. Помимо известного вредного воздействия никотина на развивающийся мозг, он вызывает привыкание и может подтолкнуть людей, особенно молодых, к потреблению более вредных форм никотина или табака. Кроме того, используя ароматизаторы и стратегии брендинга, которые привлекают молодых людей, отрасли промышленности, занимающиеся производством и маркетингом ЭСДН, применяют тактику расширения своей потребительской базы под видом содействия работе в области общественного здравоохранения. Использование ЭСДН также может подорвать существующие меры борьбы против табака, например, путем освобождения этих изделий от налогообложения или разрешения их использования в местах, свободных от табачного дыма. Уже существует значительная путаница (и смешение терминологии) в отношении категорий этих изделий. Например, бывает очень трудно отличить ЭСДН от ИНТ. Это может быть использовано табачной промышленностью в своих интересах, о чем более подробно говориться в следующем разделе. Помимо этого, по мере того как ЭСДН и другие инновационные изделия продолжают видоизменяться, также существует риск того, что они избегут регулирования из-за существующих пробелов и лазеек в нормативно-правовых документах. Со времени первоначальной оценки ВОЗ фактических данных о рисках для здоровья, связанных с использованием ЭСДН, их эффективности в помощи людям в отказе от курения, и их влиянии на борьбу против табака было опубликовано много дополнительных статей. Однако, учитывая многообразный характер ЭСДН и многочисленные достижения в разработке изделий с момента начала исследований, по-прежнему требуется больше фактических данных, чтобы сделать окончательное заключение об их воздействии на здоровье и возможности использования в качестве средства для прекращения употребления табака. Пока же существует ряд неизвестных факторов, которые означают, что ЭСДН не могут быть безопасно рекомендованы к употреблению. n В законодательстве должно быть дано строгое и четкое определение ЭСДН, чтобы страны могли эффективно их регулировать. n Страны часто имеют возможность классифицировать ЭСДН как табачные изделия. Если это возможно, страны должны обеспечить, чтобы существующие законы по борьбе против табака надлежащим образом защищали людей от потенциального вреда, наносимого ЭСДН. n ЭСДН могут служить средством приобщения молодежи к традиционному курению или к «ренормализации» курения в обществе. n Страны должны ввести запреты на рекламу и ароматизацию изделий, чтобы удержать молодых людей от использования ЭСДН. n Странам следует рассмотреть возможность введения мер политики, которые заставят производителей придавать своей продукции непривлекательный для молодежи вид, чтобы препятствовать ее использованию, например с помощью простой упаковки. Ключевая информация и рекомендации для стран Никотин вызывает привыкание, и использование ЭСДН может подтолкнуть людей, особенно молодых, к потреблению более вредных форм табака. 58 59ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Вмешательство табачной промышленности: самое большое препятствие на пути сокращения потребления табака Табачная промышленность имеет многолетний опыт систематического, агрессивного, устойчивого и хорошо финансируемого противодействия мерам борьбы против табака (84), включая усилия по подрыву жизненно важных мер борьбы против табака. Это достигается за счет использования самых разнообразных тактик, направленных на воспрепятствование, задержку, ослабление или подрыв политических обязательств и мер по борьбе против табака, принимаемых странами на международном, региональном, национальном и субнациональном уровнях. Хотя некоторые стратегии являются общеизвестными, а другие — более скрытыми (неважно, направлены ли они на правительства, население или средства массовой информации), все они имеют своей целью снижение эффективности борьбы против табака. Блокирование вмешательства табачной промышленности имеет решающее значение для успешной борьбы с глобальной табачной эпидемией и уменьшения негативных последствий употребления табака для здоровья населения. В 2011 году Генеральная Ассамблея ООН признала «наличие фундаментального конфликта интересов между табачной промышленностью и общественным здравоохранением» (85). Признавая этот явный, непримиримый конфликт интересов, и, несмотря на продолжающиеся попытки табачной промышленности позиционировать себя в качестве полноправного партнера и заинтересованного лица в борьбе против табака, Стороны Конвенции должны выполнять свои обязательства по Статье 5.3 РКБТ ВОЗ, которая требует, чтобы: «При разработке и осуществлении своей политики общественного здравоохранения по борьбе против табака Стороны действуют таким образом, чтобы защитить свою политику от воздействия коммерческих и других корпоративных интересов табачной промышленности в соответствии с национальным законодательством» (1). n запугивание правительств судебными процессами или угрозой судебного разбирательства; n манипулирование общественным мнением для улучшения своего имиджа. Новые кампании табачной промышленности продолжают подрывать борьбу против табака Чуть более десяти лет назад на рынке появились ЭСДН и ЭСДПН, наиболее распространенным прототипом которых стали электронные сигареты. Сначала эти изделия разрабатывались и продавались преимущественно нетабачными компаниями, такими как Pax Labs, Фонд за мир, свободный от табачного дыма, финансируемый Philip Morris International Фонд за мир, свободный от табачного дыма финансируется самостоятельно табачным гигантом Philip Morris International (PMI) с финансовыми ассигнованиями в размере 80 миллионов долларов США ежегодно в течение 12 лет (примерно 1 миллиард долларов США) (86). Это часть постоянной стратегии табачной промышленности, направленной на оказание влияния на научную и политическую повестку дня. Фонд финансирует научные программы и исследования, которые оказывают поддержку продукции, продаваемой PMI и другими производителями как изделия «сниженного риска», и предлагает финансирование правительствам, университетам, организациям ООН, другим международным организациям и органам общественного здравоохранения, чтобы побудить курильщиков использовать такие изделия, предположительно вместо обычных сигарет. В сентябре 2017 года ВОЗ опубликовала официальное заявление о том, что она не будет сотрудничать с Фондом, и рекомендовала правительствам и органам общественного здравоохранения последовать этому примеру (87). Секретариат РКБТ ВОЗ столь же решительно отверг сотрудничество с Фондом, подчеркнув в своем официальном заявлении, что создание Фонда за мир, свободный от табачного дыма, является очевидной попыткой нарушить РКБТ ВОЗ путем вмешательства в государственную политику, «направленной на нанесение ущерба осуществлению договора, особенно посредством реализации спорных исследовательских программ Фонда» (88). Впоследствии в 2019 году Фонд обратился с письмом к членам Исполнительного комитета ВОЗ, призывая ВОЗ изменить свою позицию по отношению к Фонду, а также «пересмотреть и решить вопрос о том, как лучше всего работать с Фондом, чтобы способствовать быстрому сокращению употребления смертельно опасных сигарет». Это предложение было отклонено Генеральным директором, который подтвердил позицию ВОЗ в своем заявлении в 2017 году (89). Вмешательство табачной промышленности принимает различные формы Обычная тактика, используемая табачной промышленностью для противодействия борьбе против табака, включает в себя (16): n вмешательство в политические и законодательные процессы; n организацию фиктивной поддержки со стороны подставных групп; n влияние на научную и политическую повестку; n бездоказательные заявления и дискредитацию проверенных научных данных; n преувеличение своей экономической значимости; которая в 2015 году представила JUUL (ЭСДН, популярную среди молодежи в США). Благодаря успешной продаже этих изделий табачная промышленность инвестировала значительные средства в их сбыт и диверсифицировала их производство наряду с выпуском табачных изделий нового поколения, таких как изделия из нагреваемого табака (ИНТ). В декабре 2018 года табачная компания Altria приобрела 35% акций JUUL за 13 миллиардов долларов США. Другие табачные компании, такие как British American Tobacco и Japan Tobacco International, также вкладывают значительные средства в производство таких изделий (90). 60 61ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Кампания «Unsmoke», проводимая Philip Morris, — пример намеренного введения в заблуждение Остановить табачные организации и изделия (STOP) Philip Morris International (PMI) — один из крупнейших мировых производителей сигарет и стойкий противник борьбы против табака. Несмотря на это, PMI пытается позиционировать себя как ответственного партнера в области общественного здравоохранения и влиять на политику борьбы против табака. Частью этого является проводимая PMI кампания «Unsmoke», которая призывает людей, «которые не бросают курить», «переходить на лучшую альтернативу», в соответствии с целью PMI «заменить сигареты бездымными изделиями, которые мы разрабатываем и продаем». Кампания подрывает инициативы по прекращению употребления табака, представляя легкую альтернативу избавлению от никотиновой зависимости и подрывая успешные инициативы по борьбе против табака (которые «денормализовали» курение во многих странах), описывая эту форму употребления табака как социально приемлемую. PMI называет свои ИНТ и ЭСДН «бездымными изделиями». Эта стратегия создает путаницу в отношении категорий этих изделий и способствует утверждению табачной промышленности о том, что продукты, выделяемые ИНТ и ЭСДН, не являются «дымом» (хотя выделяемые ИНТ продукты содержат многие токсичные химические вещества, содержащиеся в сигаретном дыме). Кампания также не признает тот факт, что последствия краткосрочного и долгосрочного использования этих изделий в большинстве своем неизвестны, и что современная наука не поддерживает утверждения о снижении риска вреда для здоровья при использовании ИНТ. PMI избегает высказываний о том, что эти изделия менее вредны, но вместо этого заявляет, что «считает» эти изделия «хотя и небезопасны … потенциально могут представлять меньший риск вреда для здоровья, чем продолжение курения».1 С помощью рекламы и лоббирования со стороны PMI и ее подставных групп, таких как Фонд за мир, свободный от табачного дыма, эта кампания старается оказать давление на правительства, чтобы они допустили эти изделия на внутренние рынки и освободили их от регулирования, применяемого к табачным изделиям, в частности от запретов TAPS, налогообложения и законов об обеспечении бездымной среды, тем самым подрывая инициативы по борьбе против табака и снижая эффективность осуществления РКБТ ВОЗ. Табачная промышленность является самым большим препятствием на пути снижения смертности, связанной с употреблением табака. Чтобы навсегда сохранить продажи своей продукции, этой промышленности нужна как можно более слабая нормативно- правовая среда. Другими словами, она должна добиться того, чтобы политика борьбы против табака не вступала в силу или была неэффективной. Для достижения этой цели табачная промышленность использует множество стратегий. В 2018 году Благотворительный фонд Bloomberg Philanthropies учредил STOP (Остановить табачные организации и изделия) — первый международный орган, контролирующий табачную промышленность. Миссия STOP состоит в том, чтобы разоблачать действия этой промышленности, подрывающие общественное здоровье, и поддерживать усилия по противодействию ее вмешательству в политику. STOP работает по всему миру, уделяя особое внимание странам с низким и средним уровнями дохода, где табачная промышленность активно нацелена на местные сообщества, и где самые многочисленные группы населения подвержены риску развития заболеваний, связанных с употреблением табака. STOP предоставляет активистам, политикам и журналистам платформу для доступа к самой свежей информации о табачной промышленности, включая разоблачения ее злоупотреблений и тактик, анализ ее действий, а также новые инструменты для борьбы с ее вмешательствами. Работа STOP включает в себя: n сбор данных и инвестирование в комплексные исследования; n реагирование на запросы политиков о помощи через службу быстрого реагирования; n разоблачение и оспаривание стратегий табачной промышленности путем взаимодействия с местными и международными средствами массовой информации; n сотрудничество между сетью по борьбе против табака и другими секторами для обеспечения всестороннего подхода к противодействию тактикам табачной промышленности. В первые 6 месяцев своей работы STOP мобилизовал поддержку ВОЗ со стороны более чем 279 организаций и частных лиц из 50 стран, чтобы публично отвергнуть подход к сотрудничеству со стороны фонда, финансируемого Philip Morris International. STOP также разоблачил десятки организаций из более чем двадцати стран как союзников табачной промышленности, которые работали над поддержкой политики, благоприятной для употребления табачных изделий. Лица, формирующие политику, активисты и журналисты могут искать в общедоступной базе данных эти организации в своих странах и изучать доказательства их связи с табачной промышленностью. STOP представляет собой партнерство между Исследовательской группой по борьбе против табака Университета Бата, Глобальным центром надлежащего управления в области борьбы против табака, Департаментом Союза по борьбе против табака и организацией Vital Strategies. Дополнительная информация размещена на веб- сайте: exposetobacco.org. Противодействие тактикам табачной промышленности Приверженность противодействию вмешательству табачной промышленности имеет основополагающее значение для успешного осуществления эффективных мер борьбы против табака в соответствии с РКБТ ВОЗ, Статья 5.3 которой обязывает Стороны действовать таким образом, чтобы защитить политику общественного здравоохранения от воздействия коммерческих и других корпоративных интересов табачной промышленности в соответствии с национальным законодательством. В 2008 году Конференция сторон (КС) РКБТ ВОЗ приняла руководящие принципы осуществления Статьи 5.3. Они были разработаны на основе как научных данных, так и опыта Сторон (91). Целью руководящих принципов является «обеспечение всеобъемлющего характера и эффективности усилий по защите мер борьбы против табака от воздействия коммерческих и других корпоративных интересов табачной промышленности». В них четко указано, что правительства должны ограничить взаимодействие с табачной промышленностью и избегать партнерских отношений с ней, а также что правительства не должны принимать финансовые или иные взносы от табачной промышленности или от тех, кто занимается продвижением ее интересов. Руководящие принципы по-прежнему играют важную роль в борьбе с вмешательством табачной промышленности и должны применяться как к сформировавшимся, так и к развивающимся табачным рынкам, где, как уже было описано, табачная промышленность пытается представить себя в качестве партнера в борьбе против табака и снижении вреда, одновременно блокируя усилия по регулированию табачных изделий. Эффективные действия правительства по противодействию вмешательству табачной промышленности в прекращение употребления табака включают следующее: n Требование раскрытия и четкого информирования об источниках финансирования научно- исследовательских учреждений, научных работников и научных исследований для предотвращения появления необъективных научных данных, на которых может основываться политика, а также для выяснения возможной заинтересованности неправительственных организаций, торгово-промышленных ассоциаций, групп потребителей, аналитических центров, профессиональных ассоциаций и других лиц, стремящихся принять участие или внести свой вкладу в политику борьбы против табака. n Отказ от партнерских отношений, а также не имеющих обязательной силы и не обеспеченных правовой санкцией соглашений с табачной промышленностью и с теми, кто работает в ее интересах, включая финансовую поддержку и одобрение деятельности табачной промышленности, связанной с борьбой против табака. n Повышение информированности относительно известных аддиктивных и вредных свойств табака и никотиносодержащих продуктов, а также вмешательства табачной промышленности в осуществление политики борьбы против табака. n «Денормализация» и, насколько это возможно, регулирование и запрет популяризации деятельности, характеризуемой табачной промышленностью в качестве «социально ответственной». n Требование о привлечении табачной промышленности к ответственности за ложную информацию, представляемую в маркетинговых кампаниях. n Регулирование ИНТ как табачных изделий в соответствии с РКБТ ВОЗ и регулирование ЭСДН согласно соответствующим решениям КС (Решение FCTC/COP6 и Решение FCTC/ COP7). n Требование, чтобы информация, предоставляемая табачной промышленностью, была открытой и точной, и чтобы эта информация на регулярной основе правдиво, полно и четко описывала деятельность самой табачной промышленности. n Наличие эффективной политики в области конфликта интересов, действующей в отношении директивных органов и должностных лиц, участвующих в разработке, осуществлении и обеспечении соблюдения политики по борьбе против табака. Блокирование вмешательства табачной промышленности имеет решающее значение для успешной борьбы с глобальной табачной эпидемией и уменьшения негативных последствий употребления табака для здоровья населения. 1 См.: https://www.pmi.com/glossary-section/glossary/smoke-free-products (по состоянию на 06.04.2019) 62 63ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Тактика табачной промышленности, препятствующая прекращению употребления табака В последние годы табачная промышленность все более активно продвигает изделия, которые, как утверждают ее представители, могут помочь людям отказаться от обычного курения. Эти изделия, которые включают ИНТ, ЭСДН и ЭСДПН, часто рекламируются табачной промышленностью как изделия «сниженного риска» (по сравнению с обычными сигаретами) и/или изделия для прекращения курения, которые могут помочь потребителям табака или курильщикам обычных табачных изделий бросить традиционное курение. Такие действия имеют последствия для реальных инициатив по оказанию помощи в прекращении употребления табака, поскольку они могут дезинформировать и вводить в заблуждение потребителей и дезориентировать правительства. В этой связи руководящие принципы осуществления Статьи 14 РКБТ ВОЗ определяют выражение «прекращение употребления табака» как «процесс прекращения употребления любого табачного изделия с чьей-либо помощью или без нее». Бездоказательные заявления и оказание влияния на научные исследования На момент составления данного доклада нет достаточного количества фактических данных, чтобы рекомендовать использование ЭСДН в качестве средства для прекращения употребления табака на уровне всего населения. Существующие исследования имеют значительные ограничения, включая ошибку выборки, неадекватные меры воздействия и слабый контроль. Более того, значительная часть доступной литературы финансируется производителями ЭСДН, в том числе табачной промышленностью, чья коммерческая заинтересованность приводит к неизбежному конфликту интересов (60). В случае ИНТ, поскольку они являются табачными изделиями, переход от обычных табачных изделий, таких как сигареты, к использованию ИНТ не считается отказом от употребления табака. В этом контексте существует риск того, что маркетинговые стратегии табачной промышленности, ориентированные на «отказ от курения» или «переход», приведут потребителей табака, регулирующие органы и лиц, принимающих решения, к объединению этих двух понятий. Объединение категорий изделий Табачная промышленность использовала разногласия в медицинском сообществе (вызванные неубедительными фактическими данными о достоинствах этих изделий как средств помощи в отказе от курения) относительно потенциальной пользы ЭСДН в качестве средства, помогающего бросить курить. Поэтому неудивительно, что в некоторых странах действуют менее жесткие нормативные требования в отношении ЭСДН по сравнению с обычными табачными изделиями, и там, где сложилась такая ситуация, табачная промышленность нередко ее использует для своей выгоды, предлагая ИНТ в качестве электронных изделий, аналогичных ЭСДН, чтобы договориться о возможности применения к ИНТ механизмов регулирования, аналогичных тем, которые применяются к ЭСДН. Это создает путаницу в отношении категорий этих изделий и может привести к тому, что ограниченные фактические данные о возможности использования некоторых видов ЭСДН в качестве средства помощи в отказе от курения при определенных условиях также будут ошибочно отнесены и к ИНТ. Например, название ИНТ «iQOS» компании Philip Morris International (которое является аббревиатурой от выражения «I quit ordinary smoking» («Я бросил обычное курение» (72)) может способствовать возникновению этого ложного впечатления. Некоторые страны и регионы, включая Соединенное Королевство, Францию и ЕС, оставили открытой возможность лицензирования новых и инновационных изделий в качестве фармацевтической продукции, включив необходимые положения в свои соответствующие законы или директивы, до получения фактических данных, подтверждающих такую возможность, и одобрения со стороны соответствующих органов. Однако, согласно имеющейся у нас в настоящее время информации, ни одно из этих изделий не присутствует на рынке в качестве средства для прекращения курения. ИНТ часто рекламируются, особенно регулирующим органам, как «обычные средства для отказа от курения». Однако существует ограниченное количество фактических данных о том, как использование ИНТ влияет на традиционное курение, или об относительном вреде использования ИНТ по сравнению с курением обычных сигарет. Манипулирование общественным мнением для улучшения своего имиджа Наблюдаемые в последнее время попытки крупных табачных компаний позиционировать себя как сторонников «снижения вреда» является хорошим примером манипулятивной стратегии табачной промышленности. Пространные и громкие заявления, дезинформация, основанная на необоснованных утверждениях, и лоббирование со стороны табачных компаний, представляющих себя как партнеров, участвующих в решении проблемы сокращения распространенности употребления табака, могут повлиять на общественное мнение. Такая лоббистская деятельность продвигает новую линейку изделий, которые, как утверждается, являются изделиями «сниженного риска», «не имеющими запаха» или «не дающими дыма», и предлагает «более чистые альтернативы» обычным сигаретам. Эта деятельность изображает табачные компании как ответственных партнеров в борьбе за прекращение курения среди взрослых, преуменьшая при этом значение установленных фактов того, что сигареты по-прежнему составляют 97% объема мирового табачного рынка, на котором доминируют одни и те же компании. Стратегическая реклама, направленная на поддержание употребления никотина или табака Рекламные кампании табачной промышленности направлены на то, чтобы дистанцировать эти изделия от сигарет, утверждая, что они «не связаны с горением» и образуют «пар», а не дым. Это является основным аргументом того, что эти изделия должны быть освобождены от действия законов об обеспечении бездымной среды и других законов. Сотрудники крупнейших магазинов хорошо обучены и имеют опыт в привлечении потенциальных потребителей в свои магазины и активно предлагают эти изделия как более приятные для использования, чем курение или употребление обычных табачных изделий, иногда утверждая, что они более приемлемы в социальном отношении и могут использоваться в тех местах, где курение запрещено. Такое вмешательство может помешать людям, пытающимся бросить курить, отказаться от этой привычки, поскольку эти изделия активно продаются для поддержания потребления никотина или табака. Это также может негативным образом сказаться на практике использования испытанных никотиновых и безникотиновых фармакотерапевтических препаратов (которые, как доказано, помогают курильщикам отказаться от употребления табака), поскольку вместо этих препаратов курильщики, желающие бросить курить, могут выбрать ЭСДН/ЭСДПН и ИНТ. Теперь, когда регулирование этих изделий становится все более распространенным явлением, табачная промышленность активно противодействует попыткам включить ЭСДН/ЭСДПН в существующее антитабачное законодательство. 64 65ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Бразилия отмечает выдающиеся достижения в борьбе против табака n Усилия и приверженность Бразилии борьбе против табака начались в 1981 году, когда Министерство здравоохранения создало Комиссию по изучению последствий употребления табака. n В 1988 году в Конституции Бразилии было определено, что реклама табачных изделий должна подлежать законодательным ограничениям и содержать предупреждения о вреде для здоровья. n В 1999 году была создана Национальная комиссия по борьбе против табака для поддержки роли страны в переговорах по первому Глобальному договору в области здравоохранения (под эгидой ВОЗ), который впоследствии стал РКБТ ВОЗ. Бразилия также была избрана председателем Межправительственного органа по переговорам по этому договору. n В 2003 году Бразилия была одной из первых стран, подписавших этот договор, и ратифицировала его в ноябре 2005 года, несмотря на то что она была развивающейся страной и крупным производителем табака. n В 2003 году была создана Национальная комиссия по осуществлению РКБТ (CONICQ), председателем которой стал министр здравоохранения. n В 2018 году Бразилия ратифицировала Протокол о ликвидации незаконной торговли табачными изделиями, который будет способствовать защите достижений и максимальному усилению воздействия экономически эффективных инструментов борьбы против табака, таких как повышение налогов на табачные изделия. История борьбы против табака в Бразилии Потребление табака в Бразилии сокращается Защита людей от табачного дыма n В Бразилии в 1996 году было запрещено курение в закрытых общественных местах и на рабочих местах внутри помещений, за исключением специально предназначенных для курения помещений. В 2011 году закон был ужесточен путем введения требования о полном запрете на курение в закрытых общественных местах, на рабочих местах и в общественном транспорте, что всецело согласуется со статьей 8 РКБТ ВОЗ. n Бразилия была первой страной с населением более 100 миллионов человек, объявившей все общественные и рабочие места свободными от табачного дыма. Предложение помощи в целях прекращения употребления табака n С начала 1990-х годов Национальный институт онкологии Бразилии (INCA) проводит подготовку медицинских работников в области проведения лечения табачной зависимости. В 2001 году Министерство здравоохранения также начало использовать национальную бесплатную телефонную линию для бросающих курить, и в настоящее время номер этой линии указывается на лицевой стороне упаковок с курительным табаком. n В 2002 году лечение табачной зависимости было официально включено в бразильскую систему общественного здравоохранения, благодаря чему в 2002 году антитабачные меры в Бразилии стали полностью соответствовать Статье 14 РКБТ ВОЗ. Поначалу лечение, направленное на прекращение употребления табака, проводилось только в специализированных медицинских учреждениях, но в 2004 году эта услуга стала оказываться в учреждениях первичной медико-санитарной помощи. n В период с 2005 по 2014 год более 800 000 курильщиков имели доступ к лечению табачной зависимости в рамках системы общественного здравоохранения Бразилии. Предупреждение об опасностях, связанных с табаком n Первые предупреждения, гласившие: «Министерство здравоохранения предупреждает: курение опасно для вашего здоровья», были напечатаны на пачках сигарет в Бразилии в 1988 году. Это предупреждение было обновлено в 1990-х годах, чтобы наконец предупредить потребителей о том, что курение вызывает рак легких, болезни сердца и другие заболевания. n В 2001 году Бразилия законодательно утвердила первую серию графических предупреждений о вреде для здоровья с использованием изображений, занимающих 100% задней стороны сигаретных пачек. На каждой стороне упаковки рядом с сообщением: «Безопасных уровней потребления этих веществ не существует» появился номер телефонной линии для бросающих курить. Этот закон также запрещал использование оберток или других элементов, которые могли бы скрыть графические предупреждения о вреде для здоровья. n Бразилия полностью соблюдала положения Статьи 11 РКБТ ВОЗ в 2003 году, еще до вступления договора в силу. n В 2004 году в Бразилии была выпущена вторая серия графических предупреждений о вреде для здоровья, включающих более убедительные изображения и сообщения, которые необходимо было включить в рекламу табачных изделий в пунктах продажи. Эти предупреждения содержали следующие сообщения: «Продажа несовершеннолетним лицам младше 18 лет запрещена в соответствии с законами 8.069/1990 и 10.702/2003» и «Данное изделие содержит более 4700 токсичных веществ и никотин, которые вызывают физическую и психологическую зависимость. Безопасных уровней потребления этих веществ не существует». n К тому времени, когда в 2008 году был опубликован первый Доклад ВОЗ о глобальной табачной эпидемии, Бразилия не только соблюдала положения Статьи 11 РКБТ, но и была одной из трех стран в мире, которые потребовали, чтобы графические изображения предупреждений о вреде для здоровья занимали 100% задней стороны сигаретных пачек. n Третья серия предупреждений была выпущена в 2008 году. Изображения этой серии были выбраны как наиболее впечатляющие по результатам исследования, проведенного Национальным институтом онкологии, результаты которого были использованы несколькими странами Северной и Южной Америки для обоснования своей политики в отношении графических предупреждений о вреде для здоровья. n В 2011 году предупредительные надписи о вреде для здоровья были расширены и теперь занимают 30% передней стороны упаковки табачных изделий в дополнение к 100% задней стороны упаковки. В мае 2018 года была выпущена новая серия графических предупреждений о вреде для здоровья. Обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий n В 2000 году Федеральный закон запретил рекламу табака в средствах массовой информации, таких как телевидение, радио, журналы, газеты и рекламные щиты, а также запретил некоторые виды косвенной рекламы и стимулирования продажи. n В 2011 году в Федеральный закон были внесены поправки, включающие полный запрет на рекламу табачных изделий в пунктах продажи, а также запрет на рекламные скидки и одновременное использование бренда, что позволило Бразилии стать страной, полностью соблюдающей положения Статьи 13 РКБТ ВОЗ. Однако закон по-прежнему разрешает выставлять на витрину табачные изделия в пунктах продажи, но при этом требует размещать графические предупреждения о вреде для здоровья на стеллажах для выкладки товара. Повышение налогов на табачные изделия n Сигареты, выпускаемые в Бразилии, когда-то были шестыми из самых дешевых сигарет в мире, но по сравнению с 2007 годом налоги на табачные изделия значительно выросли. К 2011 году была принята политика установления минимальных цен и повышены налоги на табачные изделия, что привело к увеличению доли налога в розничной цене сигарет. n По состоянию на 2018 год налоги на табачные изделия составляют 82,97% от розничной цены самого продаваемого бренда, что делает Бразилию страной с самой высокой ставкой налога на табачные изделия среди всех государств-членов в Американском регионе ВОЗ. n Бразилия успешно участвовала в субрегиональных форумах, призванных дать странам возможность обмениваться опытом и осуществлять техническое сотрудничество по вопросам налогообложения табачных изделий. Все четыре страны Американского региона ВОЗ, которые вводят самые высокие налоги на табачные изделия, расположены в Южной Америке, что делает этот субрегион лидером по использованию этих налогов в качестве инструмента снижения ценовой доступности табачных изделий.Те ку щ ие п ок аз ат ел и ку ре ни я си га ре т (% ) в Б ра зи ли и (с то ли цы ш та то в) Мужчины в возрасте 18+ Женщины в возрасте 18+ Оба пола в возрасте 18+ 2007 0 5 15 10 20 25 2017 15.6 12.3 19.5 13.2 7.5 10.1 Меры MPOWER в Бразилии Потребление табака в Бразилии сокращается n Распространенность курения среди взрослого населения снизилась с 35% в 1989 году до 18,5% в 2008 году (92). По данным Национального опроса о состояния здоровья населения, распространенность курения в 2013 году составила 14,7%. Согласно телефонному опросу, посвященному НИЗ, курение сигарет среди взрослых в столицах штатов снизилось с 15,6% в 2007 году до 10,1% в 2017 году. n Несмотря на снижение показателей курения среди взрослых, распространенность курения среди молодежи остается стабильной и составляет около 5%, причем 19% мальчиков и 17% девочек впервые пробуют курить в школьные годы, согласно данным PeNSE за 2015 год. Антитабачная кампания, проводимая Министерством здравоохранения Бразилии, 2019 год. 66 67ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Эффективные меры борьбы против табака Мониторинг употребления табака и стратегий профилактики Предложение помощи в целях прекращения употребления табака Обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий Защита людей от табачного дыма Предупреждение об опасностях, связанных с табаком Повышение налогов на табачные изделия 68 69ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Мониторинг служит основой для понимания и измерения усилий по борьбе против табака Мониторинг употребления табака и программ борьбы против него крайне важен для эффективной борьбы с табачной эпидемией и оценки результатов осуществления РКБТ ВОЗ и мер MPOWER в каждой стране. Системы мониторинга должны отслеживать показатели употребления табака, включая курение сигарет и других Мониторинг употребления табака и стратегий профилактики МОНИТОРИНГ МОНИТОРИНГ РАСПРОСТРАНЕННОСТИ УПОТРЕБЛЕНИЯ ТАБАКА — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД 0 1,750 3,500875 Kilometers Monitoring the prevalence of tobacco use – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо Страны с наивысшим уровнем достижений: Австралия, Австрия, Азербайджан, Армения, *Багамские Острова, Бангладеш, Бельгия, Болгария, Бразилия, Бруней-Даруссалам, Бутан, Венгрия, Вьетнам, Германия, Греция, Грузия, Дания, Египет, Индонезия, Иран (Исламская Республика), Ирландия, Исландия, Испания, Италия, Казахстан, Камбоджа, Канада, Катар, Коста-Рика, Кувейт, Лаосская Народно-Демократическая Республика, Латвия, Ливан, Литва, Люксембург, Малайзия, Мальта, Монголия, Мьянма, Нидерланды, Новая Зеландия, Норвегия, Острова Кука, Пакистан, Палау, Панама, Перу, Польша, Португалия, Республика Корея, Республика Молдова, Российская Федерация, Румыния, Сербия, Сингапур, Словакия, Словения, Соединенное Королевство, Соединенные Штаты Америки, *Суринам, Таиланд, Турция, Украина, Уругвай, Филиппины, Финляндия, Франция, Хорватия, Чешская Республика, Чили, Швейцария, Швеция, Эквадор, Эстония и Япония. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. Статья 20 Рамочной конвенции ВОЗ по борьбе против табака гласит: «… Стороны устанавливают эпиднадзор за масштабами, структурами, детерминантами и последствиями потребления табака и воздействия табачного дыма… Стороны включают программы эпиднадзора за табаком в национальные, региональные и глобальные программы эпиднадзора за состоянием здоровья, с тем чтобы обеспечить сопоставимость и возможность анализа данных на региональном и международном уровнях …» (1). Почти 40% населения мира охвачено надежными системами мониторинга употребления табака В 74 странах 2,8 миллиарда человек, или 38% населения мира, защищены надежными системами мониторинга, в которых используются результаты недавно проведенных, репрезентативных и периодических опросов взрослого населения и молодежи. Большинство из этих стран (44) являются странами с высоким уровнем дохода. Но, несмотря на наличие достаточных ресурсов, 25% стран с высоким уровнем дохода все еще не получили данные об употребления табака среди своего населения за последние пять лет. И хотя достаточно эффективный мониторинг осуществляется во всех кроме двадцати семи странах мира, до сих пор нет стран с низким уровнем дохода, проводящих мониторинг на уровне передовой практики, хотя он может стать более доступным с финансовой точки зрения, если включить его в мероприятия по укреплению систем здравоохранения. Проведение постоянного мониторинга употребления табака является сложной задачей для стран с низким и средним уровнями дохода В мире насчитывается 35 стран (с общим населением 2 миллиарда человек), располагающих недавними и репрезентативными данными как по взрослым, так и по молодежи, которым нужно лишь обеспечить повторное проведение обоих опросов каждые 5 лет для вывода мониторинга на уровень передовой практики. Большинство из этих стран (23) являются странами со средним уровнем дохода, шесть — с высоким уровнем дохода, и шесть — с низким уровнем дохода. Если бы все 35 стран достигли уровня передовой практики, то в странах, обеспечивающих эффективный мониторинг табачной эпидемии, проживало бы 4,8 миллиарда человек (63% населения мира). Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи 44 30 6 23 16 37 6 6 3 12 12 6 видов курительного табака (например, сигар, трубок, биди, кальянов), бездымных табачных изделий (например, жевательного табака) и других табачных изделий, таких как вапорайзеры для табака и изделия из нагреваемого табака, а также нетабачных форм употребления никотина (например, электронных сигарет). Также необходимо осуществлять мониторинг воздействия мер политики по борьбе против табака (38) и деятельности табачной промышленности (93), поскольку своевременно собранные и достоверные данные способствуют надлежащему осуществлению политики, точному измерению силы ее воздействия и последующей корректировке стратегий, и все это в значительной степени повышает вероятность успеха (94). 70 71ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Все большему числу стран необходимо проводить мониторинг всех форм употребления табака, а также электронных систем доставки никотина Ретроспективные данные показывают, что после вступления в силу РКБТ ВОЗ в 2005 году и начала проведения мониторинга в 2007 году не было достигнуто никакого очевидного прогресса до тех пор, пока страны, впервые приступившие к мониторингу табачной эпидемии, не начали завершать свой второй раунд обследований в 2011–2012 годах. Хотя, начиная с 2014 года, прогресс, по- видимому, замедлился, ожидается, что по мере публикации результатов недавно завершенных обследований уровни охвата мониторингом в 2016 и 2018 годах будут пересмотрены в сторону увеличения. Число потребителей табака остается неизменно высоким Сегодня во всем мире насчитывается в общей сложности 1,4 миллиарда потребителей табака в возрасте 15 лет и старше — 1,07 миллиарда курильщиков и 367 миллионов потребителей бездымного табака — причем небольшая часть из них употребляет как курительный, так и бездымный табак. Это число немного уменьшилось по сравнению с 2007 годом, когда в мире насчитывалось 1,46 миллиарда потребителей табака. В настоящее время табак употребляют 1,12 миллиарда мужчин (на 5 миллионов меньше, чем в 2007 году) и 279 миллионов женщин (на 58 миллионов меньше, чем в 2007 году). Несмотря на то что три из каждых четырех стран запретили продажу табачных изделий несовершеннолетним в возрасте до 18 лет, а еще 10 стран установили даже более высокие возрастные ограничения для покупки табака, по оценкам, во всем мире 24 миллиона детей в возрасте 13–15 лет курят, а 13 миллионов употребляют бездымный табак. Показатели курения снижаются во всех группах стран с разными уровнями дохода В период с 2007 по 2017 год показатели курения во всем мире снизились в среднем с 22,5% до 19,2%, что означает относительное снижение на 15% за 10 лет. Люди в странах с низким уровнем дохода курят примерно в два раза меньше, чем в странах с высоким уровнем дохода, и это соотношение мало изменилось за данный период времени. Относительное снижение показателей курения в странах с высоким уровнем дохода составило 20%, а в странах с низким уровнем дохода — 19%. В странах со средним уровнем дохода относительное снижение составило всего 12%. Показатели курения в странах со средним уровнем дохода, где проживает три четверти мирового населения, отражают среднемировой показатель. Хотя показатели курения в среднем снижаются быстрее всего в странах с высоким уровнем дохода, в совокупности они по-прежнему имеют самые высокие средние показатели курения среди всех групп стран с разными уровнями дохода в 2017 году (21,6%). За это же десятилетие курение среди мужчин снизилось с 37,1% до 32,7%, а курение среди женщин — с 8,0% до 5,8%. В 2017 году показатели курения среди женщин в странах с высоким уровнем дохода по-прежнему остаются самыми высокими среди всех групп стран с разными уровнями дохода (16,4%), что более чем в четыре раза превышает средний показатель курения среди женщин в странах с низким и средним уровнями дохода (3,5%). Напротив, самые высокие показатели среди мужчин наблюдаются в странах со средним уровнем дохода (35,3%), что почти в два раза превышает средний показатель среди мужчин в странах с низким уровнем дохода (20,2%). Необходимо ускорить борьбу против табака, чтобы избежать дальнейшего роста числа курильщиков К 2030 году, когда будет оценен конечный положительный результат в достижении Целей в области устойчивого развития, ожидается, что средний показатель курения в мире снизится примерно до 16%. Для того чтобы показатель курения упал ниже 16%, странам необходимо активизировать свои усилия. Ожидается, что в странах с высоким и средним уровнями дохода показатели курения достигнут примерно 17%, если сохранится существующая тенденция. Прогнозируется, что в странах с низким уровнем дохода показатели курения к 2030 году опустятся ниже 10%, но только в том случае, если эти страны будут внимательно следить за тем, чтобы их не настигла табачная эпидемия. Глобальные прогнозы в отношении курения среди мужчин и женщин демонстрируют разительный контраст: к 2030 году показатель курения среди женщин снизится примерно до 4%, в то время как показатель курения среди мужчин останется высоким — 28%. Этот сценарий будет означать дальнейший рост числа курящих мужчин в связи с ростом численности населения — с 908 миллионов в 2017 году до 913 миллионов в 2030 году. Чтобы предотвратить такое катастрофическое развитие событий, необходимо принять срочные меры, особенно в отношении мужчин в странах со средним уровнем дохода, где число курильщиков может достичь к 2030 году 750 миллионов. ПРОГРЕСС В ОБЛАСТИ МОНИТОРИНГА (2007–2018 ГОДЫ) ТЕКУЩАЯ РАСПРОСТРАНЕННОСТЬ КУРЕНИЯ СРЕДИ ВЗРОСЛЫХ, 2007–2017 ГОДЫ Примечание: Хотя среднее время между началом сбора данных проводимых обследований и предоставления отчетов неизвестно, опыт составления настоящего доклада показывает, что для получения полного перечня опросов в странах, проведенных в конкретном году, требуется около 4 лет. Поэтому данные за 2016 и 2018 годы являются неполными. 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 1.6 1.6 1.6 1.7 2.6 3.1 2.8 61 61 67 79 80 74 63 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 0% 5 10 15 20 25 30 35 40 Страны с низкими доходами Мир в целомСтраны со средним уровнем дохода Страны с высоким уровнем дохода Ра сп ро ст ра не нн ос ть (в п ро це нт ах ) 2007 2017 21.6 27.0 19.5 22.1 19.2 22.5 13.9 11.2 72 73ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД 0% 5% 10% 15% 20% 25% 30% 2007 2015 2020 2025 2030 Ра сп ро ст ра не нн ос ть (в п ро це нт ах ) Страны с низким уровнем дохода Мир в целом Страны со средним уровнем дохода Страны с высоким уровнем дохода Сплошная линия обозначает тенденции, выявленные по результатам опросов, пунктирная линия обозначает прогнозируемые тенденции. ТЕНДЕНЦИИ ТЕКУЩЕЙ РАСПРОСТРАНЕННОСТИ КУРЕНИЯ СРЕДИ ЛИЦ В ВОЗРАСТЕ 15 ЛЕТ И СТАРШЕ, ПО ОЦЕНКАМ ВОЗ За последние 2 года несколько стран Восточно- Средиземноморского региона ВОЗ добились отличных результатов в мониторинге употребления табака. Ливан и Судан, в частности, преодолели серьезные проблемы, связанные с завершением очень важных опросов в отношении бремени употребления табака среди своего населения, что позволило кардинальным образом изменить ситуацию с постоянной нехваткой данных об употреблении табака. В 2017 году Ливан внедрил поэтапный подход ВОЗ к эпиднадзору (STEPS), включающий использование Вопросов в отношении употребления табака (TQS) для мониторинга воздействия антитабачных мер и употребления табачных изделий, таких как кальян и наргиле. В опросе участвовали сирийские беженцы — труднодоступная группа населения, учитывая их постоянное перемещение по территории страны. Это был первый общенациональный опрос, в ходе которого были получены сопоставимые показатели для мигрантов и местного населения, и его результаты помогли стране оценить существующие меры политики и рекомендовать необходимые изменения. Тем временем Судан также провел свой первый в истории TQS в рамках опроса STEPS, запланированный и проведенный в сотрудничестве с Федеральным министерством здравоохранения, Центральным статистическим бюро и ВОЗ. Проведение опроса населения, проживающего в отдаленных и затронутых конфликтом районах, представляло собой серьезную проблему. Чтобы ее преодолеть, сборщики данных координировали действия с военными страны, чтобы иметь возможность для безопасного передвижения. Данные, полученные на основе TQS, помогли определить конкретные географические районы и людей из групп риска, в отношении которых можно применить более целенаправленные меры. Преодоление трудностей при проведении опросов в регионе Восточного Средиземноморья Эффективный эпиднадзор за факторами риска развития неинфекционных заболеваний, Индонезия В период с 2007 по 2017 год показатели курения во всем мире снизились в среднем с 22,5% до 19,2%, что означает относительное снижение на 15% за 10 лет. Команда RISKESDAS проводит работы на местах в Джакарте, Индонезия, 2018 год. Обследовательская группа проводит интервью с применением поэтапного подхода ВОЗ к эпиднадзору (STEPS), Судан, 2018 год. Употребление табака является ведущей причиной предотвратимой смертности и заболеваемости в Индонезии, чей Национальный институт научных исследований и разработок в области здравоохранения (NIHRD) с 2004 года проводит мониторинг употребления табака и других факторов риска развития НИЗ с помощью Национального опроса о состояния здоровья населения. В 2007 году был создан Riset Kesehatan Dasar (RISKESDAS, или «Фундаментальные исследования в области здравоохранения») — комплексное общенациональное обследование населения, которое дополняет и опирается на общемировые стандарты, такие как поэтапный подход ВОЗ к эпиднадзору (STEPS) и Глобальная система эпидемиологического надзора за потреблением табачных изделий, включая Глобальный опрос взрослого населения о потреблении табака. Успех RISKESDAS заключается в его всестороннем охвате всех основных факторов риска НИЗ, а также в его способности предоставлять надежные оценки на районном, региональном и национальном уровнях — важный фактор, учитывая децентрализованный характер оказания медицинской помощи в Индонезии. Особое внимание уделяется завершению опроса и публикации результатов в течение нескольких месяцев, что позволяет максимально повысить их своевременность и практическую ценность. Начиная с первого RISKESDAS в 2007 году, NIHRD проводил опрос каждые 5 лет, завершив последний раунд в 2018 году. Благодаря 100-процентному национальному финансированию, ее интеграции с другими ключевыми показателями здоровья и ее значимости для лиц, формирующих политику, эта инициатива существует уже в течение долгого времени. Модуль RISKESDAS, предназначенный для изучения вопросов, связанных с табаком, позволяет собирать информацию о возрасте лиц, начинающих употреблять табак, моделях его потребления, попытках бросить курить, воздействии вторичного табачного дыма и использовании электронных сигарет. Данные могут быть отсортированы по ключевым возрастно-половым и социально-демографическим характеристикам и показывают, что распространенность курения среди лиц в возрасте 15 лет и старше увеличилась с 27% в 1995 году до 33,8% в 2018 году. Информация о том, как употребление табака меняется среди разных групп населения, имеет важное значение для планирования стратегий, которые наиболее эффективно остановят табачную эпидемию. Результаты RISKESDAS помогли центральным и районным органам власти в планировании, основанном на фактических данных, а также в проведении мониторинга и оценки. 74 75ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Защита людей от табачного дыма Статья 8 РКБТ ВОЗ гласит: «… научные данные недвусмысленно подтверждают, что воздействие табачного дыма является причиной смерти, болезней и инвалидности … [Стороны] принимают и осуществляют … меры, обеспечивающие защиту от воздействия табачного дыма на рабочих местах внутри помещений, общественном транспорте, в закрытых общественных местах и, в соответствующих случаях, в других общественных местах» (1). Руководящие принципы осуществления Статьи 8 РКБТ ВОЗ направлены на оказание Сторонам содействия в выполнении их обязательств, предусмотренных Статьей 8 РКБТ ВОЗ, и предоставление четкого плана-графика для принятия соответствующих мер (в течение 5 лет с момента вступления в силу РКБТ ВОЗ для данной Стороны) (95). ЗАКОНОДАТЕЛЬСТВО ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫОБЕСПЕЧЕНИЕ БЕЗДЫМНОЙ СРЕДЫ — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД Вторичный табачный дым убивает Воздействие вторичного табачного дыма может привести к тяжелым и смертельным заболеваниям, включая сердечно- сосудистые, респираторные и онкологические заболевания (96–99). Дети и младенцы особенно восприимчивы к вторичному табачному дыму и подвержены повышенному риску развития респираторных заболеваний, заболеваний среднего уха и синдрома внезапной детской смерти (100–105). Плоды у беременных женщин, подвергающихся воздействию вторичного табачного дыма, больше подвержены риску мертворождения, врожденных пороков развития и более низкой массы тела при рождении (105). Не существует безопасного уровня воздействия вторичного табачного дыма, и даже кратковременное воздействие может причинить вред (106). Почти все некурящие люди, живущие с курильщиками, подвержены большему риску преждевременной смерти и развития заболеваний (107). Единственный способ надежно защитить как курильщиков, так и некурящих от вторичного табачного дыма — это полностью отказаться от курения внутри помещений (107). Чтобы законы об обеспечении бездымной среды эффективно работали, они должны носить всеобъемлющий характер Законы об обеспечении бездымной среды очень эффективны в снижении вредного воздействия табачного дыма и улучшении качества воздуха внутри помещений, как для курильщиков, так и для некурящих (108–110). Однако чтобы быть действенными, они должны носить всеобъемлющий характер. Существует ошибочное мнение, что места, свободные от табачного дыма, и помещения, специально предназначенные для курения, защищают некурящих людей от вторичного табачного дыма. Единственная мера, полностью защищающая от вторичного табачного дыма, — это создание бездымной среды, не допускающей никаких исключений (111–113). Важно напомнить странам, что безопасного уровня воздействия вторичного табачного дыма не существует. Помещения для курения, включая отдельные комнаты, специально отведенные места для курения, системы вентиляции, воздухообмена и фильтрующие устройства, не являются достаточной защитой и не могут устранить весь вторичный табачный дым (98, 110, 111). Исключения ослабляют силу воздействия законов об обеспечении бездымной среды. Законы об обеспечении бездымной среды спасают жизни Имеются убедительные доказательства того, что в юрисдикциях с законодательными запретами на курение сокращается количество госпитализаций по поводу острого коронарного синдрома и снижается смертность от заболеваний, связанных с курением (111). Законы об обеспечении бездымной среды также «денормализуют» курение, поощряя более здоровое поведение, например отказ от курения в домах и автомобилях (114–116). Создание среды, свободной от табачного дыма, может также побудить курильщиков сократить употребление табака, предпринять попытку бросить курить и совсем отказаться от употребления табака в долгосрочной перспективе (117, 118). Законы об обеспечении бездымной среды популярны и не наносят ущерба бизнесу Законы об обеспечении бездымной среды не только спасают жизнь, но и относительно легко принимаются, а их соблюдение осуществимо с экономической и политической точки зрения. Все большее число стран продолжает принимать на национальном и субнациональном уровне всеобъемлющие законы об обеспечении бездымной среды. Несмотря на утверждения табачной промышленности об обратном, наиболее тщательно разработанные исследования показывают, что законы об обеспечении бездымной среды не имеют неблагоприятных экономических последствий для бизнеса, в том числе для гостиничной индустрии (119–121). В случае их принятия, законы об обеспечении бездымной среды находят поддержку у подавляющего большинства населения (122, 123). Только 22% населения мира защищено полными запретами на курение в общественных местах, на рабочих местах и в общественном транспорте Всеобъемлющее законодательство об обеспечении бездымной среды действует в 62 странах с общим населением более 1,6 миллиарда человек (что составляет 22% мирового населения). Разница между группами стран с разными уровнями дохода на удивление невелика: примерно в каждой третьей стране из каждой группы действует полный запрет. Две из каждых трех стран по-прежнему продолжают подвергать свое население опасностям, связанным с вторичным табачным дымом, из-за слабых или отсутствующих законов об обеспечении бездымной среды, при этом 41 страна с высоким уровнем дохода, 68 стран со средним уровнем дохода и 24 страны с низким уровнем дохода обеспечивают своим гражданам слабую защиту или оставляют их полностью незащищенными. Из них 24 страны (с общим населением 372 миллиона человек) вообще не имеют запретов, и 21 страна из этих 24 — это страны с низким и средним уровнями дохода. В остальных 109 странах действуют частичные запреты, которые не соответствуют требованиям полного запрета на курение в общественных местах и на рабочих местах. 0 1,750 3,500875 Kilometers Smoke-free environments – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены/ не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) 18 8 11 6 16 10 4 6 1 13 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 34 26 3 24 15 Страны, территории и районы с наивысшим уровнем достижений: Австралия, Албания, *Антигуа и Барбуда, Аргентина, Афганистан, Барбадос, *Бенин, Болгария, Бразилия, Бруней-Даруссалам, Буркина-Фасо, *Бурунди, Венесуэла (Боливарианская Республика), *Гайана, *Гамбия, Гватемала, Гондурас, Греция, Египет, Иран (Исламская Республика), Ирландия, Испания, Камбоджа, Канада, Колумбия, Конго, Коста-Рика, Лаосская Народно-Демократическая Республика, Ливан, Ливия, Мадагаскар, Мальта, Маршалловы Острова, Намибия, Науру, Непал, *Ниуэ, Новая Зеландия, Норвегия, оккупированная палестинская территория, включая восточный Иерусалим, Пакистан, Панама, Папуа-Новая Гвинея, Перу, Российская Федерация, Румыния, Сальвадор, Северная Македония, Сейшельские Острова, Соединенное Королевство, Суринам, *Таджикистан, Таиланд, Тринидад и Тобаго, Туркменистан, Турция, Уганда, Уругвай, Чад, Чили, Эквадор и Ямайка. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. 76 77ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ПРОГРЕСС В ОБЛАСТИ ЗАКОНОДАТЕЛЬСТВА ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ (2007–2018 ГОДЫ) 2007 2008 2010 2012 2014 2016 2018 Чи сл о ст ра н 0.2 0.4 0.9 1.3 1.5 1.6 1.6 10 32 45 51 55 62 15 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 0 1 2 3 4 5 6 7 8 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 0 50 75 100 125 150 175 200 25 Пришло время, чтобы среда, полностью свободная от табачного дыма, стала социальной нормой За последние 2 года семь стран присоединились к группе стран, обеспечивающих защиту своих граждан от табачного дыма на уровне передовой практики, причем во всех общественных местах в этих странах курение полностью запрещено. Пять из этих стран, в которых закон об обеспечении бездымной среды либо отсутствовал (Бурунди, Ниуэ), либо был очень слабым и затрагивал не более двух общественных мест (Антигуа и Барбуда, Гамбия, Таджикистан), ввели полный запрет на курение, распространяющийся на все общественные и рабочие места. Две другие страны (Бенин и Гайана) ужесточили уже действующие, но недостаточно строгие законы, чтобы достичь уровня передовой практики. Четыре из этих семи стран являются странами с низким уровнем дохода. Еще восемь стран доработали свои законы об обеспечении бездымной среды, но не достигли полного охвата. Хотя с 2007 года, когда только в 10 странах действовали всеобъемлющие законы об обеспечении бездымной среды, наблюдается устойчивый прогресс в отношении внедрения таких законов, достижения стран с низким и средним уровнями дохода были особенно впечатляющими. За эти 11 лет 40 стран с низким и средним уровнями дохода (более чем каждая четвертая страна) приняли всеобъемлющие законы об обеспечении бездымной среды, тогда как только 12 стран с высоким уровнем дохода (каждая пятая страна) сделали то же самое. Население, защищенное во всем мире законодательством об обеспечении бездымной среды на уровне передовой практики, в период после 2007 года увеличилось с 232 миллионов до 1,6 миллиарда. Всеобъемлющее законодательство об обеспечении бездымной среды является популярной мерой политики Одиннадцать стран с общим населением 120 миллионов человек могли бы присоединиться к 62 другим странам, где действуют всеобъемлющие законы об обеспечении бездымной среды, если бы ввели запрет на курение еще в одном месте: Тонга (университеты); Корейская Народно-Демократическая Республика (государственные учреждения); Замбия, Маврикий, Острова Кука и Украина (внутренние служебные помещения); Сенегал (рестораны); Бутан (кафе, пабы, бары); и Венгрия, Грузия и Кипр (общественный транспорт). Пятнадцати странам с общим населением 1,7 миллиарда человек достаточно лишь исключить в своих законах возможность использования помещений, специально предназначенных для курения, а другим пятнадцати странам с общим населением 1,6 миллиарда человек — ввести запрет на курение еще в двух местах, чтобы достичь уровня передовой практики. Из 505 миллионов человек (6,6% населения мира), проживающих в одном из 100 крупнейших городов мира, только 284 миллиона (в 47 городах) защищены всеобъемлющим законом об обеспечении бездымной среды. В пяти из этих городов (Бандунг, Джакарта, Медан, Пекин и САР Гонконг) такие законы действуют в городах, в десяти — на уровне штатов или провинций, а в остальных 32 — в масштабах всей страны. Вместо того чтобы ждать принятия национальной стратегии, оставшиеся 53 крупнейших города мира, население которых в настоящее время не защищено наиболее эффективными национальными мерами политики, могли бы перейти к использованию мер, принятых на уровне города, штата или провинции, чтобы как можно быстрее защитить своих многочисленных граждан. Всеобъемлющее законодательство об обеспечении бездымной среды действует в 62 странах с общим населением более 1,6 миллиарда человек (что составляет 22% мирового населения). 78 79ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Город Сиань вводит положение о запрете курения во дворце Дамин в 2018 году. Встреча с представителями общественности в Гамбии с целью их привлечения к информированию людей о вреде, причиняемом табаком и вторичным табачным дымом, с использованием наглядных пособий ВОЗ. Еще один город Китая стал свободным от табачного дыма В Гамбии общественные места становятся свободными от табачного дыма Сиань уже давно является одним из самых популярных туристических направлений в мире, и ежегодно его посещают более 200 миллионов человек (население города — 10 миллионов жителей). В августе 2018 года под руководством муниципального законодательного управления и при решительной поддержке со стороны муниципального правительства Сианя город принял постановление о запрете курения на всех рабочих местах внутри помещений, в общественном транспорте и в закрытых общественных местах. Решительная поддержка со стороны комиссии по здравоохранению, международного сообщества и местных НПО помогла принять это постановление и защитить миллионы граждан и гостей города от вредного воздействия вторичного табачного дыма. Были начаты широкомасштабные кампании по просвещению и информированию населения для популяризации нового положения о запрете курения, и были приложены значительные усилия, направленные на обеспечение его соблюдения. Муниципальное правительство объявило конкурс среди различных государственных учреждений, ответственных за обеспечение соблюдения положения о запрете курения, с целью поощрения их активной работы в этом направлении, и попросило ежемесячно представлять свои данные о количестве наложенных штрафов, обучающих мероприятиях и информационно-пропагандистских кампаниях. По состоянию на апрель 2019 года было проинспектировано более 155 000 мест проведения мероприятий и взыскано более 240 000 юаней в виде штрафов и пени. На протяжении более чем 1000 лет Сиань как место, откуда брал начало Великий шелковый путь, играл критически важную роль в торговле и экономике региона. Теперь его ведущая роль в отношении введения запретов на курение будет вдохновлять другие города уделять большое внимание здоровью своих граждан и гостей. Мир надеется на сохранение в ближайшем будущем этой лидирующей роли Сианя и городов Великого шелкового пути, свободных от табака. В 2015 году Гамбия предприняла шаги по разработке закона о борьбе против табака и защите здоровья своих граждан. Этот закон, принятый в декабре 2016 года и официально введенный в действие в июле 2017 года, а также четкое руководство со стороны Министерства здравоохранения (при поддержке ВОЗ) и эффективное многосекторальное взаимодействие помогли стране добиться существенного прогресса. В то время как предыдущее законодательство об обеспечении бездымной среды требовало, чтобы люди не курили в общественных закрытых местах, эти запреты были неполными, разрешая организовывать места для курения или помещения, специально предназначенные для курения, почти во всех типах общественных мест. Новый закон сделал важный шаг вперед, устранив эти исключения, и введя полный запрет на курение во всех местах. В 2018 году был создан национальный комитет по борьбе против табака для содействия принятию этого закона, который вступил в силу 18 июля 2018 года. В то же время гражданское общество было мобилизовано для повышения информированности населения о вредных последствиях курения, особенно в общественных местах. ВОЗ предоставляла техническую поддержку и руководящие указания Министерству здравоохранения и привлекала к работе Министерства финансов, юстиции, начального и среднего образования, высшего образования, информации и связи, туризма, торговли, промышленности и занятости, иностранных дел, молодежи и спорта, а также Совет по медицинским исследованиям и средства массовой информации. В настоящее время, когда действует законодательство об обеспечении бездымной среды, важно следить за его соблюдением во всех общественных местах и обеспечивать исполнение этого закона для достижения максимального положительного воздействия на здоровье населения Гамбии. 80 81ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Предложение помощи в целях прекращения употребления табака уровнем дохода (Исламская Республика Иран). Три страны (Бруней-Даруссалам, Израиль и Панама) прекратили работу своих бесплатных телефонных линий для бросающих курить, а три другие страны прекратили компенсировать затраты на никотинзаместительную терапию (НЗТ). Несмотря на то что с 2007 года прогресс в отношении применения меры «O» был менее заметен по сравнению с реализацией других мер MPOWER, число стран, внедривших услуги по прекращению курения на уровне передовой практики, тем не менее, увеличилось с 10 (5% населения мира) в 2007 году до 23 (32% населения мира) в 2018 году, и это означает, что теперь эта мера защищает еще 2 миллиарда человек. Численность населения, которому предлагались самые эффективные услуги по прекращению курения в 2018 году, в шесть раз больше, чем в 2007 году (когда эта численность составляла всего 401 миллион человек). В 67 странах, где проживает 2,1 миллиарда человек, в пакете мер поддержки прекращения употребления табака отсутствует только один элемент для достижения уровня передовой практики: (i) национальная бесплатная телефонная линия для бросающих курить; (ii) компенсация затрат на НЗТ; или (iii) компенсация затрат на услуги по отказу от курения в медицинских учреждениях или по месту жительства. Из этих 67 стран 28 должны добавить национальную бесплатную телефонную линию для бросающих курить, чтобы обеспечить всестороннюю поддержку в отказе от употребления табака еще 805 миллионам человек, в то время как 38 стран должны предложить НЗТ с компенсацией затрат чтобы охватить дополнительно 1,3 миллиарда человек, а одна страна (Кот-д’Ивуар) должна начать компенсировать затраты на одну или несколько услуг по прекращению употребления табака в медицинских учреждениях или по месту жительства, чтобы охватить еще 25 миллионов человек. Из 505 миллионов человек (6,6% населения мира), проживающих в одном из 100 крупнейших городов мира, только половина (255 миллионов в 49 городах) имеет доступ к надлежащей поддержке в отказе от употребления табака. Из этих ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат)6 72 16 8 1100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 16 1 1 14 7 11 5 16 37 Чуть более 30% населения мира охвачено всеобъемлющими услугами по прекращению употребления табака По состоянию на 2018 год всеобъемлющие услуги по прекращению употребления табака действуют для 2,4 миллиарда человек в 23 странах — 32% мирового населения. Многие страны, принимающие всеобъемлющие меры по прекращению употребления табака, отстают в использовании других мер MPOWER, и только 16 стран с высоким уровнем дохода, шесть стран со средним уровнем дохода и одна страна с низким уровнем дохода (Сенегал) предлагают всестороннюю поддержку в прекращении употребления табака. Во всем мире почти все страны с высоким уровнем дохода предоставляют услуги по прекращению употребления табака, а 90% из них также предлагают как минимум частичную компенсацию затрат на эти услуги. Большинство стран со средним уровнем дохода (72%) делают то же самое, тогда как только 24% стран с низким уровнем дохода предлагают какую-либо компенсацию затрат. Двадцать четыре страны вообще не оказывают поддержки в отказе от употребления табака. Эти цифры показывают, что, хотя активная работа уже началась, еще многое предстоит сделать. 0 1,750 3,500875 Kilometers Tobacco dependence treatments – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД Спрос на услуги по прекращению курения растет — пришло время их предоставлять Доля мирового населения, охваченного всеобъемлющими услугами по отказу от употребления табака, сократилась на 1% в период с 2016 по 2018 год. Положительным моментом является то, что за последние 2 года четыре страны с общим населением 60 миллионов человек (Саудовская Аравия, Словакия, Чешская Республика и Швеция) начали предлагать всеобъемлющие услуги по прекращению курения. Однако, к сожалению, число людей, защищенных такими услугами в этих странах, недавно перенявших передовой опыт, нивелируется наличием шести стран с общим населением 97 миллионов человек, которые за тот же период выпали из группы стран с передовой практикой. Из этих стран, сокративших объем предоставляемых услуг, пять были странами с высоким уровнем дохода (Бруней- Даруссалам, Израиль, Мальта, Панама и Эстония) и одна — страной со средним Страны с наивысшим уровнем достижений: Австралия, Бразилия, Дания, Индия, Ирландия, Канада, Кувейт, Люксембург, Мексика, Нидерланды, Новая Зеландия, Объединенные Арабские Эмираты, Республика Корея, Сальвадор, *Саудовская Аравия, Сенегал, Сингапур, *Словакия, Соединенные Штаты Америки, Турция, *Чешская Республика, *Швеция и Ямайка. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. Всеобъемлющие услуги по прекращению употребления табака действуют для 2,4 миллиарда человек в 23 странах — 32% мирового населения. 82 83ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД городов в двух действуют меры, принятые на городском уровне (САР Гонконг и Лондон), а в остальных 47 — на национальном уровне. Вместо того чтобы ждать принятия национальной стратегии в отношении поддержки прекращения употребления табака, оставшийся 51 город мог бы перейти к использованию мер, принятых на уровне города, штата или провинции, чтобы как можно быстрее защитить свое многочисленное население. Приоритетность трех ключевых мер по прекращению употребления табака В комплексную программу борьбы против табака должны быть включены как минимум три меры по прекращению употребления табака: краткие консультации в учреждениях первичной медико-санитарной помощи в отношении прекращения употребления табака, бесплатные национальные телефонные линии для бросающих курить и фармакологическая терапия, которая как минимум включает НЗТ. Поддержка в отказе от употребления табака, оказываемая в учреждениях первичной медико-санитарной помощи В период после 2007 года страны со средним уровнем дохода добились заметного прогресса в оказании поддержки в отказе от употребления табака по крайней мере в некоторых учреждениях первичной медико-санитарной помощи. Доля населения, получающего поддержку в прекращении употребления табака с компенсацией затрат хотя бы в некоторых учреждениях первичной медико-санитарной помощи, увеличилась с 23% до 75%, причем самая большая часть этого увеличения приходится на страны со средним уровнем дохода. С 2012 года в странах с высоким уровнем дохода прогресс был слабым или отсутствовал, а с 2007 года в странах с низким уровнем дохода он вообще был малозаметен. В настоящее время только 18 стран оказывают поддержку по прекращению курения с полной компенсацией затрат в большинстве своих учреждений первичной медико-санитарной помощи. Бесплатная национальная телефонная линия для бросающих курить Только в одной трети стран действует национальная бесплатная телефонная линия для бросающих курить — ситуация, которая практически не изменилась за период после 2016 года. Страны со средним уровнем дохода добились наибольшего прогресса в создании национальных бесплатных телефонных линий по прекращению курения, при этом доля стран со средним уровнем дохода, где такие линии существуют, увеличилась с 10% в 2007 году до 33% в 2017 году. Национальные бесплатные телефонные линии для бросающих курить были единственной мерой по прекращению употребления табака, в применении которой наблюдался прогресс в период после 2016 года. За последние 2 года десять стран организовали телефонные линии по прекращению курения: Беларусь, Болгария, Латвия, Республика Молдова, Саудовская Аравия, Словакия, Тимор- Лешти, Туркменистан, Украина и Чешская Республика. Пять стран (Бруней-Даруссалам, Израиль, Камбоджа, Норвегия и Панама) прекратили работу своих телефонных линий для бросающих курить после 2016 года, в результате чего чистый прирост составил пять стран. ПОДДЕРЖКА В ОТКАЗЕ ОТ УПОТРЕБЛЕНИЯ ТАБАКА, ОКАЗЫВАЕМАЯ ХОТЯ БЫ В НЕКОТОРЫХ УЧРЕЖДЕНИЯХ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ (2007–2018 ГОДЫ) НАЦИОНАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОННАЯ ЛИНИЯ ДЛЯ БРОСАЮЩИХ КУРИТЬ (2007–2018 ГОДЫ)ПРОГРЕСС В ЛЕЧЕНИИ ТАБАЧНОЙ ЗАВИСИМОСТИ (2007–2018 ГОДЫ) 0% 14% 15% 97% 78% 16% 61% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 Страны с высоким уровнем дохода Страны со средним уровнем дохода Страны с низким уровнем дохода П ро це нт на я до ля н ас ел ен ия м ир а, и м ею щ ег о до ст уп к по дд ер ж ке в п ре кр ащ ен ии к ур ен ия с к ом пе нс ац ие й за тр ат в уч ре ж де ни ях п ер ви чн ой м ед ик о- са ни та рн ой п ом ощ и 0% 20% 40% 60% 80% 100% 2007 2008 2010 2012 2014 2016 2018 Страны с высоким уровнем дохода Страны со средним уровнем дохода Страны с низким уровнем доходаП ро це нт на я до ля н ас ел ен ия м ир а, п ол ьз ую щ ег ос я на ци он ал ьн ой бе сп ла тн ой т ел еф он но й ли ни ей д ля б ро са ю щ их к ур ит ь 4% 2% 6% 51% 65% 70% 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 0.4 0.8 0.9 0.9 1.0 2.4 2.4 10 16 18 19 25 2315 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 84 85ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Никотинзаместительная терапия должна быть доступной в ценовом отношении В глобальном масштабе, в то время как более двух третей стран мира предоставляют доступ к НЗТ, менее одной трети стран частично или полностью компенсируют затраты на нее. К сожалению, число стран, предоставляющих НЗТ, с 2016 года сократилось, и только 45 стран включили препараты для НЗТ в свои перечни основных лекарственных средств. Доступность НЗТ является ключевым вопросом. Страны, которые не компенсируют (или только частично компенсируют) затраты на НЗТ, рассчитывают на то, что потребители табака будут оплачивать это средство для прекращения курения из своего кармана. Анализ цен в 56 странах показывает, что (в среднем) наименее дорогой препарат для НЗТ с поправкой на паритет покупательной способности стоит на 40% меньше, чем стоимость выкуривания одной пачки самой дешевой марки сигарет в день за тот же период времени. Это означает, что, по крайней мере для заядлых курильщиков, даже оплата НЗТ из собственных средств (без компенсации затрат) при попытке бросить курить, скорее всего, будет дешевле, чем продолжение курения. Разница в цене между НЗТ и самой дешевой маркой сигарет является наибольшей в странах с высоким уровнем дохода, где значительно дешевле приобрести 8-недельный курс никотинзаместительной терапии по сравнению с покупкой 56 пачек самых дешевых сигарет. Даже в странах со средним уровнем дохода, включенных в анализ, где стоимость НЗТ значительно выше, сравнения общих затрат показывают, что цены за тот же период времени сопоставимы. В странах, где существует какая-либо форма компенсации затрат на НЗТ, стоимость самого дешевого препарата для НЗТ почти на 20% меньше, что говорит о том, что предположительно более высокий спрос на эти препараты помогает снизить расходы из собственного кармана. Следует отметить, что такая же ситуация может не отмечаться в странах с низким и ниже среднего уровнями дохода, где НЗТ, скорее всего, будет относительно дороже, а сигареты намного дешевле. Хотя использование НЗТ в качестве средства для прекращения курения доступно далеко не везде, оно относительно дешевле по сравнению со стоимостью курения. Компенсация затрат на НЗТ является важным фактором, который следует учитывать правительствам, особенно при попытке расширить доступ к проверенным и эффективным средствам для отказа от курения. НЗТ имеет наилучшее соотношение эффективности, стоимости и безопасности. В результате с 2009 года в Примерный перечень ВОЗ основных лекарственных средств были добавлены две формы НЗТ (никотиновая жевательная резинка и никотиновый пластырь) (см. https://www. who.int/medicines/publications/sexualmedicines/ en/). Примерный перечень представляет собой перечень лекарственных средств, имеющих важнейшее значение для систем здравоохранения. Странам следует рассмотреть вопрос о включении НЗТ в свои национальные перечни основных лекарственных средств. Необходимо совершенствовать меры политики и наращивать потенциал в области прекращения употребления табака Руководящие принципы осуществления Статьи 14 РКБТ ВОЗ рекомендуют внедрение четырех конкретных элементов инфраструктуры для содействия прекращению употребления табака и обеспечения эффективного лечения табачной зависимости: n Национальная стратегия прекращения употребления табака: Среди стран, по которым есть данные, почти 40% (73 из 187) имеют национальные стратегии прекращения употребления табака — от 60% стран с высоким уровнем дохода до 18% стран с низким уровнем дохода. n Национальные руководящие принципы в отношении прекращения употребления табака: Была проведена оценка национальных руководящих принципов в отношении прекращения употребления табака и клинических руководств по лечению туберкулеза, рака, сердечно-сосудистых заболеваний, диабета, хронической обструктивной болезни легких, заболеваний репродуктивной системы, психических расстройств и заболеваний полости рта. Эта оценка показала, что 82 страны (42% во всем мире) имеют национальные руководящие принципы в отношении прекращения употребления табака; и в 136 странах (73% из тех, кто прислал анкету) имеется по крайней мере одно клиническое руководство по конкретному заболеванию, которое включает вопросы прекращения курения. Две трети этих стран являются странами с низким и средним уровнями дохода. n Развитие потенциала в области подготовки кадров: В общей сложности 50 стран сообщили о регулярном обучении работников служб первичной медико-санитарной помощи проведению кратких консультаций (которые должны быть включены в программы первичной медико-санитарной помощи по профилактике заболеваний и борьбе с ними) и/или о проведении по крайней мере одной формы обучения в отношении прекращения употребления табака в рамках программ подготовки врачей, медицинских сестер и стоматологов. n Все медицинские записи содержат информацию об употреблении табака: Включение факта употребления табака в медицинские записи помогает регулярно выявлять потребителей табака и рекомендовать им бросить курить. Из всех рассмотренных компонентов инфраструктуры и систем этот был реализован в наименьшей степени. Употребление табака было СРЕДНЯЯ ЦЕНА НАИМЕНЕЕ ДОРОГОГО ВАРИАНТА НЗТ ПО СРАВНЕНИЮ С КУРЕНИЕМ САМОЙ ДЕШЕВОЙ МАРКИ СИГАРЕТ МЕРЫ ПОЛИТИКИ И СТРУКТУРНЫЙ ПОТЕНЦИАЛ ДЛЯ ПОДДЕРЖКИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНАХ Все страны Самый дешевый вариант НЗТ Стоимость выкуривания 20 сигарет в день (самой дешевой марки) 196,51 долл. США по ППС 171,65 долл. США по ППС 389,86 долл. США по ППС 244,92 долл. США по ППС 222,11 долл. США по ППС 332,94 долл. США по ППС Страны с высоким уровнем дохода Страны со средним уровнем дохода M Monitoring 0 50 100 150 200 250 300 350 400 450 М еж ду на ро дн ы е до лл ар ы (п о ПП С) отражено в обычных медицинских записях только в 35 странах. Хотя рекомендуется, чтобы меры по прекращению употребления табака осуществлялись синергетически с другими инициативами по борьбе против табака, только 45 стран сообщили об использовании информации о телефонных линиях по прекращению курения при проведении кампаний в средствах массовой информации или о включении телефонных номеров этих линий в графические предупреждения о вреде для здоровья на упаковках табачных изделий. Из стран, имеющих национальную бесплатную телефонную линию для бросающих курить, ни одна страна с низким уровнем дохода не включила номера телефонов этой линии в графические предупреждения о вреде для здоровья или указывала их при проведении кампаний в СМИ. Национальная стратегия прекращения употребления табака Клинические рекомендации по прекращению употребления табака Рекомендации по конкретным заболеваниям Отражение факта употребления табака в медицинских записях Включение номера телефонной линии для бросающих курить в предупреждения о вреде для здоровья или его указание при проведении кампаний в СМИ Развитие потенциала в области подготовки специалистов, оказывающих поддержку в прекращении употребления табака Страны со средним уровнем дохода Страны с высоким уровнем дохода Страны с низким уровнем дохода 0 20 40 60 80 100 120 140 160 Чи сл о ст ра н 6 31 14 26 29 32 46 36 19 19 0 18 40 75 10 15 3 2 86 87ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Индия является вторым по величине потребителем табачных изделий, с более чем 200 миллионами потребителей бездымных видов табака и 276 миллионами потребителей табака в целом. В 2017 году Глобальный опрос взрослого населения о потреблении табака (GATS2) показал, что 38,5% взрослых курильщиков и 33,2% взрослых потребителей бездымного табака в Индии пытались отказаться от его употребления. Правительство признало существующую потребность в экономически эффективных и доступных услугах по отказу от употребления табака и приняло комплексную стратегию по охвату потребителей табака в сельских и городских районах Индии. В дополнение к включению кратких консультаций в систему первичной медико-санитарной помощи, использованию бесплатной телефонной линии по прекращению курения и реализации Совместной рамочной программы борьбы с туберкулезом и табаком, Индия использовала технологические решения для расширения доступа к услугам по прекращению употребления табака. Национальная программа борьбы против табака и Министерство здравоохранения и благополучия семьи при поддержке ВОЗ и инициативы Международного союза электросвязи «Будь здоровым, будь мобильным» внедрили программу mCessation. Являясь частью инициативы «Цифровая Индия», эта программа использует двусторонний обмен текстовыми сообщениями между человеком, стремящимся бросить курить, и специалистами программы, обеспечивая активную поддержку тем, кто хочет отказаться от употребления табака. Уникальная особенность этой программы позволяет пользователям, которые хотят бросить курить, зарегистрироваться в ней, сделав звонок на специальный национальный номер или зарегистрировавшись на веб-сайте http:// www.nhp.gov.in/quit-tobacco. Правительство недавно выпустило вторую версию платформы mTobaccoCessation, которая способна доставлять информацию с помощью СМС или интерактивного голосового ответа на 12 языках. Прогресс в использовании программы отслеживается в режиме реального времени с помощью онлайн-панели, на которой подробно отображается количество регистраций с разбивкой по таким факторам, как пол, географическое положение и тип употребления табака. На сегодняшний день в программе зарегистрировано более 2,1 миллиона пользователей. Оценка, проведенная Министерством здравоохранения и благополучия семьи, показала, что средний показатель отказа от употребления табака через 6 месяцев после регистрации составляет 7% как для курильщиков, так и для потребителей бездымного табака. Когда у 12 000 участников программы спросили об их употреблении табака, более 19% ответили, что воздерживались от употребления в течение последних 30 дней. Индия также запустила вторую национальную программу мобильного здравоохранения, mDiabetes, для профилактики и лечения диабета. Обе программы были интегрированы в национальную инициативу по скринингу НИЗ в рамках национальной программы охраны здоровья «Ayushman Bharat». Начиная с 2005 года, Республика Корея оказывает содействие в оказании услуг по отказу от курения во всех государственных медицинских центрах по всей стране. Только с июня 2017 года по июнь 2018 года 357 936 курильщикам были даны краткие консультации в отношении прекращения курения, и 70 833 (19,8%) из них не курили в течение 6 месяцев с момента отказа от курения. В 2006 году была открыта общенациональная бесплатная телефонная линия для бросающих курить, чтобы укрепить и поддержать национальную программу отказа от употребления табака. Эта телефонная линия работает 13 часов в сутки в будние дни и 9 часов в сутки по выходным дням и предоставляет зарегистрированным пользователям бесплатные консультации в течение 1 года. Из 17 752 курильщиков табака, получивших хотя бы одну телефонную консультацию в период с 2017 по 2018 год, 3368 (19%) не курили в течение 6 месяцев с момента отказа от курения. В 2015 году Национальная служба медицинского страхования начала компенсировать в больницах и клиниках по всей стране расходы на консультации в отношении отказа от употребления табака и стоимость лекарственных средств для прекращения курения. Для оказания помощи и побуждения к отказу от курения социально обособленных курильщиков, таких как женщины и не посещающая школу молодежь, была организована служба индивидуальной поддержки, известная как «Quit Bus». Для обеспечения бесплатного интенсивного лечения заядлых курильщиков были созданы региональные центры по прекращению курения. Расширение услуг привело к увеличению числа людей, зарегистрированных в национальных службах по прекращению курения, с 439 971 в 2014 году до 861 086 в 2017 году. Использование всесторонних национальных услуг по прекращению курения способствовало значительному снижению показателей курения среди взрослых мужчин с 66,3% в 1998 году до исторического минимума в 38,1% в 2017 году. Целевое ассигнование доходов от налогообложения табачных изделий на услуги по прекращению курения и предоставление услуг по прекращению употребления табака в сочетании с другими инициативами по борьбе против него являются ключевыми факторами, которые способствовали этому успеху. Когда Сенегал в 2014 году принял Закон о борьбе против табака, Комиссия по здравоохранению Национального собрания страны подтвердила, что отказ от употребления табака является национальным приоритетом, и что будет организована всесторонняя поддержка в прекращении его употребления, чтобы помочь курильщикам отказаться от этой привычки. В то время председатель Комиссии по здравоохранению, Awa Dia Thiam, сказала членам парламента: «Необходимо принять меры для поддержки курильщиков, которые хотят бросить курить, и помочь им пройти очень трудный предварительный этап». С тех пор Министерство здравоохранения и социальной защиты создало национальную бесплатную телефонную линию по прекращению курения, на которой подготовленные консультанты могут дать совет по отказу от курения и проконсультировать звонивших о доступных в Сенегале различных методах лечения табачной зависимости, чтобы помочь им бросить курить. В течение первых 4-х месяцев на телефонную линию поступило 4068 звонков. Совсем недавно Национальная программа борьбы против табака, которая отвечает за формирование антитабачной политики, разработала Национальный стратегический план борьбы против табака на 2018–2022 годы, в котором подробно описаны доступные услуги по прекращению его употребления. Индия успешно осуществляет программу mCessation Республика Корея предлагает всестороннюю помощь в отказе от курения Консультирование в отношении отказа от курения в передвижном медпункте, известном как «Quit Bus», Республика Корея. Информация о телефонной линии для бросающих курить на пачках сигарет, Сенегал. Эквадор ратифицировал РКБТ ВОЗ в 2006 году, и, несмотря на успехи в борьбе против табака, по данным Института измерения показателей и оценки состояния здоровья (см. https://vizhub. healthdata.org/gbd-compare/), один гражданин Эквадора умирает от табака каждые 2 часа 1. Оказание поддержки в прекращении употребления табака в рамках системы здравоохранения страны по-прежнему является сложной задачей, и ее можно решить, поощряя сотрудничество с другими секторами. В этом контексте в 2018 году Эквадор предпринял шаги по интеграции кратковременных антитабачных мероприятий в систему первичной медико-санитарной помощи в соответствии со своей стратегией «Médico del Barrio» (Стратегия участкового врача) 2. В рамках этого мероприятия Министерство здравоохранения Эквадора создало национальную сеть подготовки, объединяющую учебные заведения, отвечающие за подготовку на рабочем месте работников служб первичной медико-санитарной помощи, и обратилось к ВОЗ с просьбой укрепить потенциал этой национальной сети по вопросам прекращения употребления табака. В ответ на это ВОЗ, ПАОЗ и Европейское респираторное общество (которое оказало финансовую поддержку) провели в январе 2018 года совместный семинар по обучению 55 местных преподавателей оказанию помощи в отказе от употребления табака. В марте 2018 года в провинциях Пичинча, Гуаяс, Асуай и Каньяр началась интеграция кратковременных антитабачных мероприятий в систему первичной медико-санитарной помощи. Около 120 работников служб первичной медико-санитарной помощи были обучены проведению кратковременных антитабачных мероприятий и с тех пор регулярно выявляют потребителей табака и рекомендуют им бросить курить. Результаты проекта были весьма обнадеживающими. С середины марта до середины ноября 2018 года было выявлено 3916 потребителей табака, которым были даны рекомендации по отказу от курения. Среди 2069 пациентов, наблюдавшихся в течение 4-х месяцев, показатель воздержания от курения в течение 7 дней составил 57,2%, а из 968 пациентов, наблюдавшихся в течение 6-ти месяцев, показатель воздержания составил 48,9%. Основываясь на этих результатах, Эквадор планирует распространить интеграцию кратковременных антитабачных мероприятий в систему первичной медико-санитарной помощи в большем числе провинций. Интеграция кратковременных антитабачных мероприятий в систему первичной медико-санитарной помощи, Эквадор 1 Результат отображает среднюю оценку, выраженную в исходном количестве 5372 смертей и 95%-ном диапазоне интервала неопределенности от 4669 до 6143 смертей. 2 «Medico del Barrio» – это передовая стратегия первичной медико-санитарной помощи, разработанная и реализуемая правительством Эквадора, цель которой заключается в предоставлении медицинских услуг уязвимым и приоритетным группам населения путем набора и скрининга пациентов. Эти услуги предоставляются при выезде на дом медицинских бригад, состоящих из врача общей практики, медсестры, работника первичной медико-санитарной помощи, а также при поддержке местного и семейного врача и/или врача общей практики, работающего в первичном звене здравоохранения. Мужчина получает краткую консультацию в отношении прекращения курения, Эквадор. Текстовые сообщения программы mCessation, получаемые жителями Индии на английском языке и хинди. Сенегал – первая страна с низким уровнем дохода, которая предлагает всестороннюю поддержку в отказе от употребления табака 88 89ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Предупреждение об опасностях, связанных с табаком другая мера, и 47% стран предъявляют самые строгие требования к графическим предупреждениям на упаковках табачных изделий: 65% стран с высоким уровнем дохода, 45% стран со средним уровнем дохода и 15% стран с низким уровнем дохода. Только 10% стран (пять стран с высоким уровнем дохода, девять стран со средним уровнем дохода и семь стран с низким уровнем дохода) не используют никаких предупредительных надписей, а другие 22 страны (11%) используют предупреждения, которые занимают менее 30% основной маркированной поверхности табачной упаковки (ниже минимального размера, установленного РКБТ ВОЗ). Каждая третья страна с низким уровнем дохода не использует никаких предупреждений или использует предупреждения меньшего размера, чем требуется. Статья 11 РКБТ ВОЗ гласит: «Каждая Сторона … принимает и осуществляет … эффективные меры, с тем чтобы … упаковка и маркировка табачных изделий не стимулировали продажу табачного изделия любым путем, который является ложным, вводящим в заблуждение или обманным, либо создающим неправильное впечатление о его характеристиках, воздействии на здоровье, опасностях или выделяемых продуктах» (1). Руководящие принципы осуществления Статьи 11 РКБТ ВОЗ направлены на оказание Сторонам содействия в выполнении их обязательств, предусмотренных Статьей 11 РКБТ ВОЗ, и предоставление четкого плана-графика для принятия соответствующих мер (в течение 3 лет с момента вступления в силу РКБТ ВОЗ для данной Стороны) (95). ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД Предупредительные надписи о вреде для здоровья Предупреждения о вреде для здоровья содержат важную информацию о пагубных последствиях употребления табака Несмотря на наличие огромного количества фактических данных о вреде, причиняемом табаком, многие его потребители до сих пор не в полной мере осознают опасности, которым они подвергают себя и других лиц, употребляя табачные изделия (124). Потребители имеют право быть предупрежденными о воздействии на здоровье изделий, которые они покупают и используют, и это включает в себя предоставление полной и достоверной информации об опасностях употребления табака (124–126). Графические предупреждения о вреде для здоровья, содержащие точную информацию о рисках, связанных с употреблением табака, могут помочь стимулировать потребителей табака сократить или прекратить его употребление (127, 128). Эффективные предупреждения о вреде для здоровья информируют о рисках употребления табака, а также об опасном воздействии вторичного табачного дыма на окружающих (129). Имеются убедительные фактические данные о том, что четкие, бросающиеся в глаза предупреждения побуждают потребителей табака задуматься об отказе от курения и могут привести к сокращению употребления табака (130, 131). Предупреждения о вреде для здоровья на упаковках табачных изделий являются эффективными Графические предупреждения о вреде для здоровья на упаковках табачных изделий гарантированно доходят до потребителей табака всякий раз, когда они используют эти изделия (132). В то же время нанесение предупредительных надписей на упаковку табачных изделий требует от государств относительно невысоких затрат (132). Графические предупреждения о вреде для здоровья находят более сильную поддержку со стороны общественности, чем большинство других мер борьбы против табака (129, 133). Предупреждения должны касаться конкретных последствий для здоровья, связанных с употреблением табака. Наглядные графические предупреждения, четко сформулированные и исчерпывающие, являются наиболее эффективными (134, 135). Важно, чтобы предупреждение было крупным и занимало не менее половины поверхности табачной упаковки (передней и задней) (132). Чтобы продолжать оказывать воздействие, предупредительные надписи должны регулярно меняться (136). Табачные компании используют упаковку для манипулирования восприятием потребителями вкуса, крепости и воздействия табачного изделия на здоровье, по сути, превращая табачную упаковку в характеристику изделия (137). Термины, позволяющие предположить снижение риска для здоровья, такие как «легкие», «сверхлегкие» и «с низким содержанием смол», являются обманными и должны быть запрещены (130). Однако удаления вводящих в заблуждение описательных терминов может быть недостаточно для уменьшения ошибочных представлений о сниженном риске, связанном с использованием этих типов сигарет (138, 139). Более половины населения мира охвачено воздействием крупных и эффективных графических предупреждений о вреде для здоровья Убедительные графические предупреждения о вреде для здоровья применяются в 91 стране, где проживает почти 3,9 миллиарда человек, — более половины населения мира (52%). Эта мера MPOWER защищает больше людей, чем любая 0 1,750 3,500875 Kilometers Health warning labels – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо Страны с наивысшим уровнем достижений: Австралия, Австрия, Аргентина, Армения, Бангладеш, *Барбадос, Беларусь, Бельгия, Болгария, Боливия (Многонациональное Государство), Бразилия, Бруней-Даруссалам, Буркина-Фасо, Вануату, Венгрия, Венесуэла (Боливарианская Республика), Вьетнам, *Гайана, Германия, *Гондурас, Греция, *Грузия, Дания, Джибути, Египет, Индия, Иран (Исламская Республика), Ирландия, *Испания, Италия, Казахстан, Камбоджа, *Камерун, Канада, *Кипр, Коста-Рика, Кыргызстан, Лаосская Народно-Демократическая Республика, Латвия, Литва, *Люксембург, Маврикий, Мадагаскар, Малайзия, Мальта, Мексика, Монголия, Намибия, Непал, Нидерланды, Новая Зеландия, *Пакистан, Панама, Перу, Польша, Португалия, Республика Молдова, Российская Федерация, Румыния, Сальвадор, Самоа, *Саудовская Аравия, Сейшельские Острова, Сенегал, *Сент-Люсия, Сингапур, Словакия, *Словения, Соединенное Королевство, Соломоновы Острова, Суринам, Таиланд, *Тимор-Лешти, Тринидад и Тобаго, Туркменистан, Турция, Украина, Уругвай, Фиджи, Филиппины, Финляндия, Франция, *Хорватия, Чад, Чешская Республика, Чили, Швеция, Шри-Ланка, Эквадор, Эстония и Ямайка. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. 90 91ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Четыре из каждых пяти стран с низким уровнем дохода не требуют наличия надлежащих предупреждений на упаковках табачных изделий За последние 2 года еще 14 стран, в которых проживает 4% мирового населения, присоединились к 77 странам, которые требовали наличия крупных графических предупредительных надписей на табачных изделиях. Семь из них были странами с высоким уровнем дохода, а остальные семь — со средним уровнем дохода. Из 14 стран две (Барбадос и Сент-Люсия) перешли от полного отсутствия обязательных предупреждений о вреде для здоровья к принятию закона, требующего, чтобы графические предупреждения о вреде для здоровья занимали не менее 50% поверхности табачной упаковки, а остальные 12 стран ужесточили существующие законы, чтобы соответствовать уровню передовой практики. Ни одна из стран с низким уровнем дохода за последние 2 года не добилась полного принятия законов в отношении графических предупреждений, а это означает, что четыре из каждых пяти стран с низким уровнем дохода по-прежнему не требуют наличия надлежащих предупреждений на упаковках табачных изделий. Убедительные графические предупреждения о вреде для здоровья применяются почти в половине всех стран мира, где проживает более половины мирового населения По сравнению с 2007 годом, когда только девять стран (5% населения мира) имели крупные графические предупреждения на пачках сигарет, в настоящее время в 91 стране (52% населения мира) существуют исчерпывающие требования к графическим предупреждениям на сигаретных пачках. Это означает, что в период после 2007 года 82 страны приняли меры по принятию законов, требующих наличия убедительных графических предупреждений о вреде для здоровья на табачных изделиях. Двадцать восемь государств-членов Европейского союза (ЕС) внесли значительный вклад в это увеличение, поскольку все они включили в свои национальные законы требования о наличии крупных графических предупреждений о вреде для здоровья, предусмотренные директивой ЕС 2014 года о предупредительных надписях (23 страны сделали это к 2016 году, а остальные пять — к 2018 году). Кроме того, в 2016 году Индия достигла уровня передовой практики, увеличив общий охват населения этой мерой на 1,35 миллиарда человек. Из всех мер MPOWER, начиная с 2007 года, в применении этой меры был достигнут наибольший прогресс как с точки зрения действий стран, так и с точки зрения численности населения, охваченного мерой политики на уровне передовой практики. В восьми странах с общим населением 384 миллиона человек достаточно лишь увеличить размер предупреждений на упаковках на 20% или менее, чтобы соответствовать всем критериям передовой практики в отношении крупных графических предупреждений на упаковках табачных изделий. Еще 15 стран сделали обязательным использование крупных предупреждений (занимающих не менее 50% поверхности упаковки), и для достижения уровня передовой практики им нужно добавить только один критерий. Восемь из этих 15 стран, представляющих 157 миллионов человек, должны лишь потребовать, чтобы убедительные графические предупреждения о вреде для здоровья присутствовали на каждой упаковке табачных изделий и на любой внешней упаковке, используемой в розничной торговле, а шести странам с общим населением 360 миллионов человек нужно лишь добавить требование о наличии графического изображения (вместо простого текста) — Албания, Нигер, Острова Кука, Того, Тонга и Соединенные Штаты Америки. Оставшейся стране из этой группы, Габону, с населением 2 миллиона человек необходимо лишь включить необходимый стиль, размер и цвет шрифта в требования к предупреждениям на упаковках, чтобы достичь уровня передовой практики. Из 505 миллионов человек (6,6% населения мира), проживающих в одном из 100 крупнейших городов мира, две трети (339 миллионов в 62 городах) защищены графическими предупреждениями на упаковках табачных изделий, содержащими все требуемые характеристики. Во всех этих городах действует национальное законодательство, за исключением САР Гонконг, в котором действует закон, принятый на городском уровне. ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ ПРОГРЕСС В ИСПОЛЬЗОВАНИИ ПРЕДУПРЕДИТЕЛЬНЫХ НАДПИСЕЙ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ (2007–2018 ГОДЫ) Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики 39 47 12 24 Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2 12 6 19 5 5 13 11 2007 0 1 2 3 4 5 6 7 8 2008 2010 2012 2014 2016 2018 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 0.4 0.6 0.8 1.1 1.5 3.5 3.9 9 18 29 43 77 91 14 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 Убедительные графические предупреждения о вреде для здоровья применяются в 91 стране, где проживает почти 3,9 миллиарда человек, — более половины населения мира (52%). 92 93ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Использование простой упаковки табачных изделий дает хороший эффект и повышает действенность предупреждений о вреде для здоровья Простая упаковка табачных изделий (также называемая стандартизированной упаковкой) — это упаковка, которая ограничивает или запрещает «размещение на упаковке логотипов, цветов фирменных изображений или пропагандистской информации, за исключением торгового наименования и наименования изделия, изображенных стандартным цветом и гарнитурой» (95). Использование простой упаковки одновременно уменьшает привлекательность табачных изделий, устраняет влияние табачной упаковки как формы рекламы и стимулирования продажи, сводит к минимуму воздействие вводящих в заблуждение описательных терминов и повышает заметность и эффективность предупреждений о вреде для здоровья (140– 143). Имеются фактические данные о том, что использование простой упаковки уменьшает ошибочные представления о том, что некоторые сигареты являются менее вредными, чем другие, и положительно влияет как на распространенность курения, так на поведение в отношении курения (144). Правомерность использования впервые введенной в Австралии в 2012 году простой упаковки была оспорена табачной промышленностью, которая ссылалась на свое право на защиту товарных знаков, свободу выражения мнений при ведении коммерческой деятельности, защиту торговли и свободного перемещения товаров (145). Эти возражения были отклонены национальными судами Австралии, Англии и Уэльса, Франции и Норвегии (145). Кроме того, в июне 2018 года комиссия Всемирной торговой организации вынесла негативное решение по жалобам, поданным четырьмя странами в отношении закона Австралии, касающегося упаковки табачных изделий (146). Все большее число стран требует обязательного использования простой упаковки табачных изделий Несмотря на лоббирование со стороны табачной промышленности, несколько стран в настоящее время приступают к внедрению простой упаковки табачных изделий. К концу 2018 года 10 стран (Австралия, Венгрия, Ирландия, Новая Зеландия, Норвегия, Саудовская Аравия, Соединенное Королевство, Таиланд, Уругвай и Франция) приняли законы, предусматривающие обязательное использование простой упаковки табачных изделий, и выпустили нормативные положения с указанием сроков ее внедрения. Кроме того, в 2019 году Бельгия, Канада, Сингапур и Турция приняли нормативные требования в отношении использования простой упаковки табачных изделий. Буркина-Фасо, Грузия, Израиль, Румыния и Словения приняли законы, но не нормативные положения, и еще не установили сроки внедрения простой упаковки. В Грузии отмечен один из самых высоких показателей употребления табака в мире. Около 33% взрослого населения в настоящее время курят (в том числе 57% мужчин), в дополнение к 12,6% курящих подростков в возрасте 13–15 лет. Около 11 400 граждан Грузии ежегодно умирают в результате употребления табака, и страна теряет 2,4% своего годового ВВП из-за смертей и инвалидности, связанных с табаком. Хотя первый закон о борьбе против табака в стране был принят в 2003 году, серьезное вмешательство табачной промышленности не позволило этому закону стать всеобъемлющим. Вот уже более десяти лет законы Грузии остаются неизменными. Однако в 2015 году начал формироваться план изменений. Альянс по борьбе против табака при поддержке нескольких НПО, а также при финансовой и мощной технической поддержке со стороны «Кампании за детей, свободных от табака», начал пропагандистскую кампанию, мобилизуя и консолидируя всех местных и международных участников, работающих в области борьбы против табака, здоровья и прав человека. Семнадцатого мая 2017 года был принят новый закон. Этот закон требует, чтобы графические предупреждения о вреде для здоровья занимали не менее 65% двух самых больших сторон упаковки всех курительных табачных изделий (включая сигареты, сигары, кальяны, нагреваемый табак и т. д.). Правительство Грузии постановило, что должны использоваться девять наиболее эффективных графических предупреждений (отобранных Министерством здравоохранения на основе результатов опроса целевых групп населения), разработанных в Австралии и Канаде. Упаковки бездымных табачных изделий должны содержать письменные предупреждения о вреде для здоровья, занимающие 30% двух самых больших сторон упаковки. Три графических предупреждения общего характера о вреде для здоровья и три дополнительных предупреждения с соответствующими пиктограммами должны одинаковым образом размещаться на каждом типе табачной упаковки и периодически меняться в течение года. Однако самоуспокоению не должно быть места, поскольку непрерывное вмешательство табачной промышленности продолжает подрывать усилия по борьбе против табака в Грузии, что привело к откладыванию начала использования простой упаковки табачных изделий до декабря 2021 года. По мере того как успех введения требований к использованию простой упаковки табачных изделий становится все более очевидным, все больше стран, в том числе страны со средним уровнем дохода, начинают применять эту меру. Следующие три страны первыми сделали это в своих регионах. Уругвай продолжает лидировать в Американском регионе ВОЗ В 2018 году Уругвай сохранил свою роль лидера в Американском регионе ВОЗ, став первой страной в регионе, которая ввела в действие требования об использовании простой упаковки табачных изделий. Шестого августа 2018 года Президент Уругвая Табаре Васкес подписал исполнительный указ об обязательном использовании простой упаковки. Однако всего лишь месяц спустя действие этого указа было приостановлено из-за иска, поданного компанией British American Tobacco (BAT). Административный суд первой инстанции вынес решение в пользу BAT, поскольку мера в отношении использования простой упаковки табачных изделий была введена в действие исполнительным указом, а не законом, принятым парламентом. Правительство Уругвая обжаловало это решение, и 11 октября 2018 года Апелляционный суд вынес решение в пользу правительства, хотя для утверждения простой упаковки все же потребуется принятие закона. В том же месяце были предприняты экстренные законодательные меры, что привело к принятию закона № 19.723 от 12 декабря 2018 года и развернутого указа от 29 апреля 2019 года, в соответствии с которым этом закон будет применяться ко всем табачным изделиям, начиная с 22 декабря 2019 года. Саудовская Аравия вводит простую упаковку табачных изделий В конце 2018 года Государственное управление по контролю за пищевыми продуктами и медикаментами Саудовской Аравии (SFDA) выпустило нормативные положения, требующие использования простой упаковки табачных изделий, что сделало Саудовскую Аравию первой страной в регионе Восточного Средиземноморья, применившей эту меру. В рамках подготовки к принятию закона (который будет полностью введен в действие 1 января 2020 года) SFDA представило образец простой упаковки для использования всеми производителями и импортерами табачных изделий с указанием требуемого стандартного цвета и стиля шрифта, а также примеры графических предупреждений о вреде для здоровья, выбранных из базы данных графических предупреждений о вреде для здоровья как ВОЗ, так и Регионального бюро ВОЗ для стран Восточного Средиземноморья. Ожидается, что в соответствии с концепцией Саудовской Аравии в области укрепления общественного здравоохранения на период до 2030 года этот шаг внесет свой вклад в общую повестку дня Саудовской Аравии по борьбе против табака. Таиланд стал первой страной с уровнем дохода выше среднего, которая ввела простую упаковку В декабре 2018 года Таиланд вошел в историю, став первой страной в Азии (и первой страной в мире с уровнем дохода выше среднего), которая потребовала обязательного использования простой упаковки табачных изделий — закон, который будет полностью введен в действие к 9 сентября 2019 года. «Простая упаковка табачных изделий является важной мерой борьбы против табака, которая поможет сократить употребление этих смертельно опасных изделий в Таиланде», — заявил д-р Daniel A Kertesz, представитель ВОЗ в Таиланде. Новая мера дополняет ранее действовавшее законодательство, требующее, чтобы на 85% поверхности табачных упаковок были нанесены графические предупреждения о неблагоприятных последствиях курения для здоровья. В Грузии принят новый закон в отношении предупреждений о вреде для здоровья Все большее число стран по всему миру начинает использовать простую упаковку табачных изделий Руководство по использованию простой упаковки, Уругвай. Парламент Грузии голосует за законопроект о борьбе против табака, 2017 год. 94 95ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Антитабачные кампании в средствах массовой информации Статья 12 РКБТ ВОЗ по борьбе против табака гласит: «Каждая Сторона поддерживает и укрепляет систему информирования населения по вопросам борьбы против табака, используя в соответствующих случаях все имеющиеся средства передачи информации. … каждая Сторона … содействует … широкому доступу к эффективным и всесторонним программам просвещения и информирования населения об опасностях для здоровья потребления табака и воздействия табачного дыма, включая привыкание; … [каждая Сторона содействует] информированию населения об опасностях для здоровья потребления табака и воздействия табачного дыма, а также о преимуществах прекращения употребления табака и образа жизни, свободного от табака; … [каждая Сторона содействует] информированию населения и доступу к информации об отрицательных последствиях производства и потребления табака для здоровья людей, а также о его отрицательных экономических и экологических последствиях» (1). Руководящие принципы осуществления Статьи 12 РКБТ ВОЗ (83) направлены на оказание Сторонам содействия в выполнении их обязательств, предусмотренных Статьей 12 Конвенции (95). Тщательно спланированные антитабачные кампании в средствах массовой информации могут сократить потребление табака Тщательно спланированные, энергичные антитабачные кампании в СМИ могут сократить потребление табака. Имеются убедительные фактические данные о том, что кампании в средствах массовой информации увеличивают количество попыток бросить курить, уменьшают число случаев начала употребления табака среди молодежи и подверженность воздействию вторичного табачного дыма (147–152). Антитабачные кампании в СМИ широко используются в странах с высоким уровнем дохода, но также доказали свою эффективность и в странах с низким и средним уровнями дохода (153). Непрерывно проводимые кампании с большей вероятностью окажут более долгосрочное влияние на поведение, связанное с употреблением табака, хотя и кампании продолжительностью всего 3 недели также могут дать положительный эффект (148, 154, 155). Рекламные кампании на телевидении с использованием графических изображений, как известно, особенно эффективны в мотивации потребителей табака к попыткам бросить курить (151, 156). Кампании в СМИ могут быть дорогостоящими, но они способны быстро и эффективно охватить очень большие группы населения (151), предоставляя информацию о том, что именно потребители табака могут сделать для того, чтобы бросить курить, например, указывая телефонный номер бесплатной линии по прекращению курения в рекламных продуктах — внизу рекламных постеров или в конце телевизионной рекламы. Всеобъемлющие стратегии борьбы против табака должны включать антитабачные кампании в средствах массовой информации Антитабачные кампании в СМИ не только повышают осведомленность населения КАМПАНИИ В СМИАНТИТАБАЧНЫЕ КАМПАНИИ В СМИ — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио 3 17 2 4 2 Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 7 24 19 6 2 24 2 3 6 17 43 18 6 18 и информируют людей о вредных последствиях употребления табака и воздействия вторичного табачного дыма, но и побуждают к отказу от курения. Поэтому крайне необходимо, чтобы эти кампании стали важной частью любой всеобъемлющей стратегии или программы борьбы против табака (156). Правительствам следует составлять и распространять обращения, направленные на просвещение нынешних и потенциальных потребителей табака о связанных с ним опасностях, чтобы повлиять на отношение и убеждения, касающиеся его употребления (149). Проведение антитабачных кампаний в СМИ требует в настоящее время гораздо больших усилий Менее четверти населения мира (1,7 миллиарда человек) проживает в странах, которые провели хотя бы одну общенациональную всеобъемлющую антитабачную кампанию в СМИ за последние 2 года. Из 39 стран, проводивших антитабачные кампании в то время, 19 были странами с высоким уровнем дохода, 18 — со средним уровнем дохода и 2 — с низким уровнем дохода. Почти половина стран мира (91) за последние 2 года не провели ни одной продолжительной кампании, в результате чего около 19% населения мира и около 220 миллионов потребителей табака не были охвачены какими-либо антитабачными кампаниями в СМИ. Люди в странах с низким уровнем дохода меньше всего подвергаются воздействию антитабачных кампаний в средствах массовой информации: более 60% населения, проживающего в 24 странах с низким уровнем дохода, не были охвачены какими- либо кампаниями за последние 2 года. Первым годом, в течение которого проводился мониторинг антитабачных кампаний в СМИ, был 2010 год. С тех пор доля населения мира, охваченного эффективными кампаниями в СМИ, росла до 2014 года, когда 4,2 миллиарда человек жили в странах, проводивших такие кампании. К сожалению, к 2018 году это число сократилось более чем в два раза — до 1,7 миллиарда человек. В 2015–2016 годах антитабачные кампании проводили 42 страны — больше стран, чем в любой другой период времени. Большинство стран, проводящих антитабачные кампании, не повторяют их каждые 2 года. Из 42 стран, которые проводили эффективные кампании в течение 2014–2016 годов, 33 провели еще одну кампанию за последнее время, но только в 22 из этих стран кампании соответствовали уровню передовой практики. Из 91 страны, которая не проводила никаких кампаний за последние два года, 20 уже имели опыт проведения кампаний, соответствующих уровню передовой практики. Из 14 стран, которые постоянно проводили антитабачные кампании в течение всех пяти оцениваемых периодов (2009–2010, 2011–2012, 2013–2014, 2015–2016 и 2017– 2018), только четыре страны (Австралия, Вьетнам, Соединенное Королевство и Турция) сохранили наилучшую практику проведения каждой кампании. 0 1,750 3,500875 Kilometers Anti-tobacco mass media campaigns – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо Страны с наивысшим уровнем достижений: Австралия, Австрия, *Беларусь, *Бразилия, *Бруней-Даруссалам, Вьетнам, *Германия, *Грузия, Индонезия, Иордания, *Ирак, Ирландия, Италия, *Катар, *Кипр, Коста-Рика, *Люксембург, *Мьянма, Новая Зеландия, Норвегия, Пакистан,*Панама, Республика Корея, Республика Молдова, Сальвадор, Сейшельские Острова, *Сенегал, *Сент-Люсия, Соединенное Королевство, Соединенные Штаты Америки, *Тимор-Лешти, *Того, Тонга, *Туркменистан, Турция, Фиджи, *Франция, Швейцария и Эстония. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. 96 97ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ПРОГРЕСС В ПРОВЕДЕНИИ АНТИТАБАЧНЫХ КАМПАНИЙ В СМИ (2010-2018 ГОДЫ) Примечание: Представление данных по антитабачным кампаниям в СМИ началось в 2010 году. 2007 2008 2010 2012 2014 2016 2018 2.4 4.0 4.2 3.3 1.7 39 35 37 39 42 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) Опрос, проведенный в 2014 году в Мьянме с применением поэтапного подхода ВОЗ к эпиднадзору (STEPS), показал, что 43,2% населения (62,2% мужчин и 24,1% женщин) употребляли бездымный табак, при этом 94% сообщили об употреблении жевательного табака, содержащего бетель. В целях борьбы с опасностями для здоровья, связанными с употреблением табака, в сентябре 2017 года Мьянма провела свою первую кампанию в средствах массовой информации по повышению информированности населения о вреде употребления табака для здоровья (включая бетель-квид). Национальная НПО «Фонд народного здоровья» в сотрудничестве с гражданскими властями, рекламными агентствами, СМИ и исследовательскими компаниями по всей Мьянме разработала и провела эту кампанию. Важную роль сыграла также поддержка со стороны Министерства здравоохранения и спорта и Министерства информации в виде предоставления бесплатного и недорогого эфирного времени на радио и телевидении, а также техническая и финансовая поддержка со стороны неправительственной организации Vital Strategies. Эта шестинедельная кампания стала первым случаем, когда на телевидении, радио и рекламных постерах появились истории о реальных людях, пострадавших от употребления бездымного табака в Мьянме. При разработке кампании использовался научно обоснованный стратегический коммуникационный подход, который включал определение целевой аудитории; доработку, предварительное тестирование и выпуск социальной рекламы; использование государственных и частных СМИ (телевидение, радио); а также оценку охвата населения и оказанного воздействия после проведения кампании. Кампании в средствах массовой информации по борьбе против табака были признаны ВОЗ «наиболее выгодной мерой» (28). Значительный охват аудитории, составивший 48% населения в 2017 году и более 80% в 2018 году, обнадеживает и является прекрасным примером того, как сотрудничество с участием многих заинтересованных сторон может оказать максимальное влияние на страновом уровне. Население Китая является крупнейшим потребителем табачных изделий. Несмотря на прогресс, достигнутый в продвижении инициатив по борьбе против табака, зависимость жителей Китая от табака остается достаточно сильной. Табачная промышленность продолжает проводить крупные маркетинговые кампании и по-прежнему способна расширять свою потребительскую базу и успешно привлекать новое поколение курильщиков. От болезней, связанных с употреблением табака, в Китае ежегодно умирает 1 миллион человек, а 100 000 некурящих умирают от вредного воздействия вторичного табачного дыма. В мае 2017 года Кампания «За новое поколение, свободное от табачного дыма», использовала всю мощь индустрии развлечений, объединившись со знаменитостями и модным журналом (исходя из их привлекательности, особенно для молодежи и для женщин), чтобы распространить идею о том, что выбор здорового, свободного от курения образа жизни расширяет внутренние силы и возможности. Кампания была запущена во время Всемирного дня без табака в 2017 году и получила широчайший отклик в социальных сетях, собрав 34 миллиона просмотров всего за 3 дня. Она была признана социально значимым хэштегом номер один и за первую неделю охватила более 120 миллионов пользователей социальных сетей, 70% из которых были моложе 40 лет. В течение недели в ветке обсуждения кампании присутствовало более 80 миллионов пользователей. В течение первых 30 дней 184 средства массовой информации освещали кампанию в Китае, а видео было показано на более чем 100 светодиодных экранах, размещенных на крупнейших зданиях и в наиболее посещаемых местах по всему Китаю. Даже авиакомпания Xiamen Airlines транслировала видео в своих залах ожидания по всему Китаю и в своих самолетах. Мьянма запускает первую в своей истории антитабачную кампанию в СМИ Индустрия развлечений помогает сформировать в Китае новое поколение людей, свободных от табачного дыма Кампания #stopbetelmyanmar, Мьянма. Менее четверти населения мира проживает в странах, которые провели хотя бы одну общенациональную всеобъемлющую антитабачную кампанию в СМИ за последние 2 года. Кампания «За новое поколение, свободное от табачного дыма», Китай. 98 99ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий Запреты на рекламу, стимулирование продажи и спонсорство табачных изделий должны быть всеобъемлющими Спустя более 10 лет после принятия руководящих принципов осуществления Статьи 13 РКБТ ВОЗ следующий принцип, изложенный в ее начале, по-прежнему актуален и сегодня: «Существует достаточно документированных свидетельств того, что реклама, стимулирование продажи и спонсорство табака увеличивают употребление табака, и что полный запрет на рекламу, стимулирование продажи и спонсорство табака снижает употребление табака» (95). Каждый год табачная промышленность тратит миллиарды долларов на рекламу, Статья 13 РКБТ ВОЗ гласит: «… полный запрет на рекламу, стимулирование продажи и спонсорство приведет к сокращению потребления табачных изделий. Каждая Сторона … вводит полный запрет на всю рекламу, стимулирование продажи и спонсорство табачных изделий. … каждая Сторона принимает в течение пяти лет после вступления Конвенции в силу для этой Стороны соответствующие законодательные, исполнительные, административные и/или иные меры и представляет соответствующие доклады в соответствии со Статьей 21» (1). Руководящие принципы осуществления Статьи 13 РКБТ ВОЗ направлены на оказание Сторонам содействия в выполнении их обязательств, предусмотренных Статьей 13 Конвенции (95). Запреты эффективно сокращают употребление табака Фактические данные из разных стран мира свидетельствуют о том, что полные запреты эффективны в сокращении продаж табака и его потребления (164–167). В странах с низким и средним уровнями дохода воздействие запретов TAPS может быть еще более впечатляющим, чем в странах с высоким уровнем дохода (167). Запреты TAPS признаны основной мерой политики борьбы против табака, поскольку они включают в себя одно из двух положений РКБТ ВОЗ, устанавливающих обязательные временные рамки их осуществления (вторым является статья 11 Конвенции). Запреты должны быть полными, и их соблюдение должно быть надлежащим образом обеспечено Запреты TAPS должны охватывать все виды деятельности, касающейся TAPS, включая как прямые, так и косвенные виды рекламы. Прямые виды рекламы включают, среди прочего, телевидение, радио, печатные издания и рекламные щиты, в то время как косвенные виды рекламы включают, в частности, расширение бренда, бесплатное распространение табачных изделий, ценовые скидки, выставление на витрину табачных изделий в пунктах продажи и спонсорство табака, включая программы корпоративной социальной ответственности (168). Наличие стендов с табачными изделиями в пунктах продажи «нормализует» эти изделия, побуждает к курению, способствует совершению импульсивных покупок, препятствует отказу от курения и усиливают склонность детей и молодых людей попробовать табачные изделия (169–174). Когда запреты не являются полными, табачные компании используют юридические лазейки или просто направляют свои средства на финансирование тех форм стимулирования продажи, которые не запрещены законом (164, 175, 176). Когда табачные компании делают финансовые взносы или взносы натурой любому другому субъекту на достойные дела или социально ответственные мероприятия, такие взносы подпадают под определение спонсорства табака согласно Статье 1 (g) Конвенции и поэтому должны быть 0 1,750 3,500875 Kilometers Enforce bans on tobacco advertising – Best practice countries, 2018 Страны с передовой практикой Прочие страны Неприменимо ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ — СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД Страны с наивысшим уровнем достижений: *Азербайджан, Албания, *Антигуа и Барбуда, Афганистан, Бахрейн, *Бенин, Бразилия, Вануату, *Гайана, *Гамбия, Гана, Гвинея, *Демократическая Республика Конго, Джибути, Иран (Исламская Республика), Испания, Йемен, Катар, Кения, Кирибати, Колумбия, *Конго, Кувейт, Ливия, Маврикий, Мадагаскар, Мальдивы, Монголия, Непал, Нигер, Нигерия, *Ниуэ, Объединенные Арабские Эмираты, Панама, Республика Молдова, Российская Федерация, *Саудовская Аравия, Сейшельские Острова, Сенегал, *Словения, Суринам, Того, Тувалу, Турция, Уганда, Уругвай, Чад и Эритрея. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. стимулирование продажи и спонсорство (TAPS) для продвижения своих табачных изделий и увеличения продаж табака (157). Хотя табачные компании и настаивают на том, что реклама лишь увеличивает их долю рынка за счет конкурентов, существуют многолетние и убедительные фактические данные о причинно- следственной связи между деятельностью, связанной с TAPS, и увеличением или постоянным употреблением табака как за счет эффективного привлечения новых потребителей, так и за счет препятствования попыткам отказаться от его употребления (148, 158, 159). Табачные компании используют комбинацию маркетинговых методов для охвата различных слоев населения. Деятельность, касающаяся TAPS, ведется с учетом особенностей отдельных групп населения, используя новые табачные изделия, которые обходят нормы регулирования и поддерживают социальную приемлемость употребления табака (160). Молодые люди и женщины особенно подвержены влиянию TAPS в странах с низким и средним уровнями дохода (161). Воздействие рекламы и стимулирования продажи табачных изделий повышает вероятность того, что подростки начнут употреблять табак, что, в свою очередь, может привести к более высокой распространенности употребления табака среди взрослых потребителей в будущем (159, 162, 163). Рекламная и спонсорская деятельность также эффективно влияет на бизнес, который может получить выгоду от миллиардов долларов, инвестируемых табачной промышленностью в TAPS. Чтобы противостоять этому, необходимы полные запреты на все виды деятельности, касающиеся TAPS, в качестве основной стратегии борьбы против табака (164). Число стран с низким уровнем дохода, которые ввели запрет TAPS, превышает число стран, применивших какую-либо другую меру MPOWER. 100 101ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Запрет TAPS должен применяться в отношении новых средств массовой информации Табачные компании в настоящее время часто используют новые информационные площадки для осуществления деятельности, касающейся TAPS, такие как веб-сайты социальных сетей и приложения для мобильных телефонов (178). На самых разнообразных платформах социальных сетей для продвижения табачных изделий используются популярные блогеры и представители табачных компаний, а также проводятся дискуссии, спонсируемые табачными брендами (178, 179). Широчайшее развитие коммуникационных технологий и использование мобильных телефонов для выхода в Интернет привели к необходимости контролировать рекламу и продвижение табачных изделий на таких платформах, как Instagram, YouTube, Facebook и т. д. Дети и подростки особенно подвержены влиянию информации, исходящей с этих площадок (180). Законодательство, запрещающее TAPS, не всегда может включать в себя запрет на рекламу в сети Интернет, и поэтому крайне важно обеспечить, чтобы запреты распространялись на сетевые средства массовой информации (181, 182). В некоторых случаях для обеспечения соблюдения запретов TAPS на сайтах социальных сетей может потребоваться трансграничное применение законодательства, и по этой причине странам необходимо сотрудничать и координировать свои усилия (179). Все большее число стран, чем когда-либо, вводит полные запреты на рекламу, стимулирование продажи и спонсорство табачных изделий Запрет TAPS остается мерой, которая применяется недостаточно широко, так как только 18% населения мира, проживающего в 48 странах, охвачено полным запретом. В то же время 44 страны (11 стран с высоким уровнем дохода, 21 страна со средним уровнем дохода и 12 стран с низким уровнем дохода) до сих пор не ввели никаких запретов TAPS. Обращает на себя внимание тот факт, что число стран с низким уровнем дохода, которые ввели запрет TAPS, превышает число стран, применивших какую-либо другую меру MPOWER, при этом в 14 странах с низким уровнем дохода — или в 40% — существуют полные запреты TAPS. В противоположность этому, менее 20% стран с высоким уровнем дохода (11) достигли этого уровня передовой практики. Число стран с низким уровнем дохода, которые ввели полный запрет TAPS, превышает число стран с высоким уровнем дохода, применившим эту меру За последние 2 года еще 10 стран ввели запрет на все виды прямой и косвенной рекламы, в результате чего численность мирового населения, охваченного этой мерой на уровне передовой практикой, увеличилась на 150 миллионов человек и достигла 1,3 миллиарда. Три из этих стран были странами с низким уровнем дохода (Бенин, Гамбия и Демократическая Республика Конго); четыре — странами со средним уровнем дохода (Азербайджан, Гайана, Конго и Ниуэ) и три — странами с высоким уровнем дохода (Антигуа и Барбуда, Саудовская Аравия и Словения). запрещены (168). Инициативы по созданию корпоративной социальной ответственности обычно используются для того, чтобы убедить правительства отложить и воздержаться от реализации программ борьбы против табака, и эти инициативы должны быть включены в запреты TAPS (174). Табачная промышленность пытается избежать регулирования, добровольно принимая недостаточно строгие кодексы рекламной практики, дискредитируя фактические данные о налагаемых ограничениях и используя как лоббистов, так и судебные разбирательства, чтобы избежать запретов (148, 165). Однако ограниченные запреты практически не оказывают никакого воздействия (148, 164, 177). Чтобы запреты были эффективными, они должны быть всеобъемлющими. В законодательстве должны использоваться четкие, простые формулировки и недвусмысленные определения, а также следует избегать составления перечней запрещенных видов деятельности, которые являются или могут быть восприняты как исчерпывающие (167). Кроме того, законодательство должно предусматривать строгие меры обеспечения его соблюдения и контроля, а также высокие финансовые штрафные санкции за возможные нарушения (95). ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ ПРОГРЕСС В ПРИМЕНЕНИИ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ (2007–2018 ГОДЫ) Число стран, вводящих полные запреты TAPS, неуклонно увеличивалось на протяжении многих лет, с семи стран в 2007 году до 48 стран (каждая четвертая) в 2018 году, т. е. на 41 страну. Страны с низким и средним уровнями дохода на протяжении многих лет были лидерами в принятии жестких запретов TAPS. В 2007 году все семь стран с передовой практикой введения запретов были странами с низким и средним уровнями дохода (Албания, Джибути, Исламская Республика Иран, Кения, Мадагаскар, Нигер и Эритрея). В мире в любой временной период всегда было больше стран с низким уровнем дохода, чем стран с высоким уровнем дохода, где существовали полные запреты TAPS. В настоящее время только 44 страны не ввели какие- либо запреты TAPS Тридцать стран с общим населением 2,1 миллиарда человек находятся всего в одном шаге от полного запрета на рекламу. Девяти странам нужно лишь запретить расширение бренда (Бутан, Грузия, Литва, Таиланд, Туркменистан, Финляндия Франция, Хорватия и Шри-Ланка). Семи странам нужно лишь запретить рекламу табачных изделий в пунктах продажи (Аргентина, Индия, Мали, Нидерланды, Острова Кука, Черногория и Южная Африка). Семи странам нужно лишь запретить спонсорство со стороны табачной промышленности (Вьетнам, Египет, Исландия, Новая Зеландия, Сирийская Арабская Республика, Соединенное Королевство и Судан). Четырем странам нужно лишь запретить рекламные скидки (Кипр, Ливан, Папуа-Новая Гвинея и Эфиопия). Норвегии нужно лишь запретить одновременное использование бренда, Тонге — показ табачных изделий или брендов на телевидении и/или в кино, а на оккупированной палестинской территории, включая Восточный Иерусалим — бесплатное распространение табачных изделий. Почти четверть из 505 миллионов человек (125 миллионов), проживающих в 26 из 100 крупнейших городов мира, полностью защищены от воздействия TAPS национальным законодательством. Во всех 26 городах запреты TAPS действуют на национальном уровне. Остальные 74 города в настоящее время не защищены национальным запретом TAPS, но могли бы перейти к использованию законов, принятых на уровне города, штата или провинции, и тем самым защитить в общей сложности еще 380 миллионов человек. Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) 11 37 11 23 58 21 14 8 12 Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2007 2008 2010 2012 2014 2016 2018 0.2 0.2 0.3 0.7 0.9 1.2 1.3 7 18 24 31 38 48 11 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 102 103ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Республика Конго, центральноафриканская страна, расположенная по обе стороны экватора, ратифицировала РКБТ ВОЗ в феврале 2007 года. Конвенция вступила в силу в мае 2007 года. В рамках осуществления Статьи 13 в стране были запрещены некоторые, но не все виды TAPS. Эта инициатива была усилена 4 июля 2012 года принятием и обнародованием закона о борьбе против табака, но процесс введения запретов TAPS все еще не был завершен. В июне 2018 года в Конго был принят указ, который расширил законодательство, включив в него запрет на рекламу табачных изделий в пунктах продажи, а также запрет на рекламные скидки, расширение бренда и спонсорство табачных изделий, среди прочих запретов TAPS. Конго в настоящее время является одной из 17 стран Африканского региона ВОЗ, в которых полностью запрещены все виды TAPS. Данные о соблюдении законодательства, собранные в стране для данного доклада, показывают, что большинство запретов на рекламу, вступивших в силу в 2006 году, тщательно соблюдаются в стране, что является хорошим знаком для недавно принятых запретов. В условиях глобализации Ниуэ, островное государство в южной части Тихого океана, теперь гораздо больше связан с остальным миром, чем когда-либо прежде, и поэтому стал более восприимчивым к маркетингу табачной промышленности. Однако Ниуэ, хотя и является Стороной РКБТ ВОЗ, до недавнего времени не осуществлял эффективного регулирования, касающегося TAPS. Законы о запрещении TAPS, особенно в пунктах продажи табачных изделий, являются важной составной частью защиты здоровья будущих поколений страны. В 2016 году правительство Ниуэ приступило к работе по приведению своего законодательства по борьбе против табака в соответствие требованиям Конвенции. Министерство здравоохранения провело общественные консультации с представителями государственного сектора, а также с представителями организаций гражданского общества и общественных групп, и в 2018 году был принят закон о борьбе против табака. Этот закон включает полные запреты TAPS. После принятия закона заинтересованные стороны получили больше информации о различных видах TAPS, и новый закон даже запрещает выкладку табачных изделий в пунктах продажи. В дополнение к этому закон также запрещает курение в общественных местах, на рабочих местах и в общественном транспорте; запрещает импорт и производство бездымного табака и требует размещения предупреждений о вреде для здоровья на упаковках курительных табачных изделий. В знак признания его выдающейся работы в области борьбы против табака Министерство социальных услуг Ниуэ является одним из пяти учреждений, получивших награду ВОЗ по случаю Всемирного дня без табака в 2019 году. Республика Конго ужесточает запрет TAPS Ниуэ принимает закон о борьбе против табака, вводящий запрет TAPS В 2017 году Гайана стала второй страной в англоязычном Карибском сообществе (КАРИКОМ) и в Американском регионе ВОЗ, принявшей всеобъемлющее антитабачное законодательство, предусматривающее полный запрет TAPS, наряду с требованиями о создании среды, полностью свободной от табачного дыма, и наличии предупреждений о вреде для здоровья на табачных изделиях. Эти действия способствовали тому, что Гайана прошла путь от полного отсутствия мер борьбы против табака к использованию трех «наиболее выгодных» с точки зрения ВОЗ мер (28), принятых на уровне передовой практики. Запреты TAPS, по сравнению с мерами по созданию среды, свободной от табачного дыма, и графическими предупреждениями о вреде для здоровья, не получили столь широкого распространения в Американском регионе ВОЗ или во всем мире. В отсутствие запретов TAPS табачная промышленность имеет возможность продолжать пополнять ряды потребителей табака, что делает достижение Гайаны особенно заметным. Закон Гайаны о борьбе против табака был разработан Министерством здравоохранения, которое осознало необходимость предотвращения влияния табачной промышленности при принятии нового законодательства и взяло на себя обязательство продвигать всеобъемлющую инициативу, согласующуюся со Статьей 13 (E) РКБТ ВОЗ, а также Статьями 8 (P) и 11 (W). Несмотря на то что уровень соблюдения запрета TAPS был умеренным, а уровень его соблюдения в пунктах продажи был описан как низкий, Министерство здравоохранения провело встречи с заинтересованными лицами из деловых кругов, транспортных служб, профсоюзов и ассоциаций потребителей, а также с представителями широкой общественности, чтобы повысить их вовлеченность и усилить контроль за соблюдением запретов. Гайана принимает всеобъемлющее законодательство о борьбе против табака Кампания по повышению информированности населения в отношении введения запрета на рекламу табака в пунктах продажи, Конго. Президент Гайаны и министр здравоохранения Гайаны получают награду ВОЗ по случаю Всемирного дня без табака 2018 года за усилия по борьбе против табака, включая запреты TAPS. Представители правительства и общественности вносят свой вклад в разработку проекта закона о борьбе против табака в Ниуэ, 2017 год. 104 105ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Повышение налогов на табачные изделия а половина — с тем, что они начинают меньше курить (184). Чтобы объективно оценить эти цифры, недавнее исследование показало, что повышение цен на табачные изделия на 50% в 13 отдельных странах приведет к тому, что 67 миллионов человек бросят курить (185). Налогообложение табачных изделий также не требует больших затрат, и его администрирование обходится странам с низким и средним уровнями дохода всего в 0,05 доллара США на душу населения в год (186). Обладая потенциалом огромного воздействия в сочетании с низкими затратами на внедрение, налогообложение табака по праву считается самой эффективной в экономическом плане мерой, «наиболее выгодной» с точки зрения ВОЗ, а это означает, что отдача и экономические выгоды от использования этой меры в несколько раз превышают затраты на ее внедрение (187, 188). Повышение налогов на табачные изделия увеличивает государственные доходы и может способствовать расширению финансирования сектора здравоохранения Повышение налогов не только сокращает употребление табака и улучшает здоровье, но и приносит государствам больше доходов (121). Это дополнительное финансирование может быть использовано для программ борьбы против табака, а также для других важных инициатив в области здравоохранения и социальной защиты, которые в настоящее время успешно осуществляются в некоторых странах (189, 190). Такое использование налоговых поступлений еще больше усилит общественную поддержку введения более высоких налогов на табачные изделия. Статья 6 Рамочной конвенции ВОЗ по борьбе против табака гласит: «… ценовые и налоговые меры являются эффективным и важным средством сокращения потребления табака … [Стороны должны ввести] … меры, которые могут включать: … налоговые политики и … ценовые политики в отношении табачных изделий, с тем чтобы содействовать достижению целей в области здравоохранения, направленных на сокращение потребления табака» (1). . 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Страны с передовой практикой Продажа сигарет запрещена Прочие страны Неприменимо ПОВЫШЕНИЕ НАЛОГОВ НА ТАБАЧНЫЕ ИЗДЕЛИЯ – СТРАНЫ С НАИВЫСШИМИ ДОСТИЖЕНИЯМИ, 2018 ГОД СОВОКУПНЫЙ НАЛОГ НА СИГАРЕТЫ Страны, территории и районы с наивысшим уровнем достижений: *Австралия, Австрия, *Андорра, Аргентина, Бельгия, Болгария, Босния и Герцеговина, *Бразилия, Греция, *Египет, Израиль, Иордания, Ирландия, Испания, Италия, *Колумбия, Латвия, *Маврикий, Мадагаскар, Мальта, Ниуэ, *Новая Зеландия, оккупированная палестинская территория, включая Восточный Иерусалим, Польша, *Северная Македония, Сербия, Словакия, Словения, Соединенное Королевство, *Таиланд, Турция, Финляндия, Франция, Хорватия, *Черногория, Чешская Республика, Чили и Эстония. * Страны, впервые достигшие наивысшего уровня в период после 31 декабря 2016 года. Повышение налогов на табачные изделия является весьма эффективной с экономической точки зрения мерой по сокращению употребления табака Многочисленные исследования показали, что повышение налогов для увеличения цен на табачные изделия является единственной наиболее эффективной мерой борьбы против табака (23, 121, 183). В целом, повышение цен на табачные изделия на 10% приведет к сокращению их потребления на 5% в странах с низким и средним уровнями дохода (в некоторых случаях до 8%) и примерно на 4% в странах с высоким уровнем дохода (121). Примерно половина этого сокращения связана с отказом потребителей табака от курения, Необходимо через определенные промежутки времени существенно повышать налоги на табачные изделия, чтобы снизить их ценовую доступность Табачные изделия становятся все более доступными в ценовом отношении во многих странах, где доходы и покупательная способность населения растут быстрыми темпами (191). Несмотря на то что некоторые из этих стран повысили ставки налогов на табак, этого оказалось недостаточно для компенсации инфляции и роста доходов населения, что привело к снижению реальной величины налогов и их эффективности в сокращении потребления табака (192). Незначительное повышение налогов, которое не делает табачные изделия менее доступными в ценовом отношении, вряд ли приведет к сокращению потребления табака и стимулированию отказа от курения. Правительствам необходимо контролировать ставки налогов на табачные изделия и их цены по отношению к реальным доходам населения и существенно повышать налоговые ставки через равные промежутки времени, чтобы гарантировать, что табачные изделия не станут более доступными в ценовом отношении. Политика налогообложения табачных изделий становится более эффективной, когда улучшается налоговое администрирование Ужесточение налогового и таможенного администрирования, а также укрепление потенциала правоприменительной деятельности усиливают положительный эффект повышения налогов на табачные изделия (193). Опыт многих стран показывает, что с незаконной торговлей табачными изделиями можно успешно бороться даже при повышении налогов и цен на эти изделия, поэтому угроза уклонения от уплаты налогов не должна использоваться в качестве причины для отказа от повышения налогов. С вступлением в силу Протокола РКБТ ВОЗ о ликвидации незаконной торговли табачными изделиями правительства теперь имеют в своем распоряжении больше инструментов для контроля цепи поставок и обеспечения уплаты надлежащих налогов. С другой стороны, налоговое администрирование может стать проще при осуществлении правильной налоговой политики. Среди различных видов налогов, взимаемых с табачных изделий, акцизы являются наиболее эффективными с точки зрения повышения цен и существенного положительного влияния на здоровье людей (194). Более простые структуры налогообложения также легче администрировать — следует избегать использования сложных структур и многоуровневых акцизных сборов, чтобы не допустить возникновения ситуации, при которой может быть сведена к минимуму польза от налогов на табачные изделия с точки зрения воздействия на здоровье населения и на объем налоговых поступлений. В период с 2016 по 2018 год численность населения мира, защищенного высокими налогами на табачные изделия, увеличилась в два раза Повышение цен на табачные изделия путем повышения табачных налогов — наиболее эффективный и действенный способ сокращения употребления табака — является наименее используемой мерой MPOWER, поскольку в 2018 году только 14% населения мира проживало в 38 странах с достаточно высокими налогами на табачные изделия. Большинство стран, которые уже ввели высокие налоги на табачные изделия, являются странами с высоким уровнем дохода. До сих пор лишь очень небольшое число стран с низким и средним уровнями дохода (15 стран, или 11%) ввели высокие налоги на табак. После 2016 года 10 стран Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены 14 35 38 13 1 1 3 18 4 1 8 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 23 24 5 3 3 Примечание: Бруней-Даруссалам и Бутан исключены из статистики в отношении меры R, поскольку продажа сигарет в этих странах запрещена. 0 1,750 3,500875 Kilometers Raise taxes on tobacco – Best practice countries, 2018 Страны с передовой практикой Продажа сигарет запрещена Прочие страны Неприменимо 106 107ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД повысили налоги до уровня, составляющего или превышающего 75% от цены самой продаваемой марки сигарет. Население этих 10 стран, 462 миллиона человек, теперь защищено более высокими налогами. Семь из этих стран были странами со средним уровнем дохода: Бразилия, Египет, Колумбия, Маврикий, Северная Македония, Таиланд и Черногория. Остальные три были странами с высоким уровнем дохода: Австралия, Андорра и Новая Зеландия. Наиболее значительное увеличение доли налогов в 10 странах было произведено в Колумбии, где ставка налога увеличилась с 49,5% в 2016 году до 78,4% к 2018 году. После 2016 года ни одна из стран с низким уровнем дохода не повысила налоги до 75% или более от розничной цены сигарет. Действительно, после 2016 года только одна страна с низким уровнем дохода (Либерия) повысила налоги в достаточной мере, чтобы приблизиться на одну категорию к уровню передовой практики. А с 2016 года три страны (Кипр, Литва и Украина) выбыли из группы стран с передовой практикой, поскольку не смогли сохранить свою долю налогов на уровне 75% или выше. В 2018 году население планеты, защищенное высокими налогами на табачные изделия, перешагнуло отметку в 1 миллиард После 2008 года прогресс в повышении налогов на табачные изделия был на удивление малозаметен. Численность населения, защищенного высокими налогами на табак, оставалась на отметке около полумиллиарда в течение 8 лет, и только за последние 2 года это число превысило 1 миллиард. Однако если в 2008 году только одна страна из девяти ввела налоги, составляющие 75% или более от розничной цены сигарет, то в 2018 году это число почти удвоилось: население почти каждой пятой страны теперь находится под защитой высоких налогов на табачные изделия. Девять стран с высоким уровнем дохода повысили налоги в достаточной степени, чтобы достичь наивысшего уровня реализации этой меры после 2008 года, в то время как три страны с высоким уровнем дохода (Германия, Португалия и Сейшельские Острова) выбыли из этой группы. Девять стран со средним уровнем дохода достигли самого высокого уровня налогообложения после 2008 года, а три страны со средним уровнем дохода (Кения, Куба и Тунис) опустились на одну группу ниже. Одна страна с низким уровнем дохода (Мадагаскар) в 2010 году начала взимать налоги на уровне 75% или выше от розничной цены сигарет и в настоящее время остается единственной страной с низким уровнем дохода, где эта мера реализована на максимальном уровне. В 2008 году 82% из полумиллиарда человек, защищенных высокими налогами на табачные изделия, проживали в странах с высоким уровнем дохода. Сегодня в странах со средним уровнем дохода проживает более половины населения (54%), защищенного этой мерой. В странах с низким уровнем дохода проживает только 3% людей, защищенных таким способом. ПРОГРЕСС В ОТНОШЕНИИ УСТАНОВЛЕНИЯ СОВОКУПНОГО НАЛОГА НА СИГАРЕТЫ В РАЗМЕРЕ, ПРЕВЫШАЮЩЕМ 75% ИХ РОЗНИЧНОЙ ЦЕНЫ (2008–2018 ГОДЫ) Все большее число стран применяет рекомендуемые структуры табачных акцизных сборов В настоящее время все больше стран применяют структуры акцизов на сигареты, как это было рекомендовано в предыдущих изданиях Доклада ВОЗ о глобальной табачной эпидемии. Из 181 страны, отслеживаемой в семи докладах, число стран, вводящих специфическую структуру акцизного налогообложения, увеличилось с 57 до 62 в период с 2008 по 2018 год, а число стран, вводящих смешанную структуру акцизного налогообложения, которая в большей степени зависит от специфического акциза, увеличилось с 22 до 37 за тот же период времени. Количество стран, опирающихся на адвалорные акцизы, сократилось с 55 в 2008 году до 41 в 2018 году. По состоянию на 2018 год только 15 стран не облагают акцизами табачные изделия. Это значительное сокращение по сравнению с 2008 годом, когда в 23 странах не применялись акцизы на табачные изделия. Примечательно, что 11 из 15 стран, не взимающих табачных акцизов, относятся к странам с низким и средним уровнями дохода. В 2018 году полмиллиарда человек проживало в странах с уровнем налогов на табачные изделия в пределах 5 процентных пунктов от самого высокого уровня налогообложения Каждая третья страна (62) взимает налоги, которые не достигают 75%-ного уровня, но составляют 50% или более от розничной цены табачных изделий. В двадцати из этих стран (с общим населением в полмиллиарда человек) налоги составляют 70% или более от розничной цены, поэтому эти страны находятся в пределах 5 процентных пунктов от уровня налогообложения, соответствующего передовой практике. Еще 12 стран (с общим населением 352 миллиона человек) находятся в пределах 10 процентных пунктов от такого уровня налогообложения. Если бы все 62 страны этой категории повысили налоги до 75%, то еще 4,7 миллиарда человек были бы защищены этой мерой, то есть в общей сложности поразительное число в 5,7 миллиарда человек — 75% населения мира — были бы защищены высокими налогами. На сегодняшний день более четверти из 505 миллионов человек, проживающих в одном из 100 крупнейших городов мира (141 миллион человек в 29 городах), защищены достаточно высокими налогами на сигареты. В каждом из этих 29 городов налоговые ставки устанавливаются на национальном уровне. Ни один город еще не ввел независимо от правительства страны такие налоги на табачные изделия, которые привели бы к увеличению доли совокупных налогов до 75% и более от розничной цены сигарет. 2008 2010 2012 2014 2016 2018 0 1 2 3 4 5 6 7 8 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 0.5 0.5 0.5 0.6 0.6 1.0 2.4 23 31 33 31 38 28 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 Страны с высоким уровнем дохода Страны со средним уровнем дохода Страны с низким уровнем дохода Мир в целом Ц ен а и ра зм ер н ал ог ов н а па чк у си га ре т (д ол л. С Ш А п о П П С) Цена: 4,99 долл. США по ППС Цена: 7,80 долл. США по ППС Цена: 3,09 долл. США по ППС Цена минус налоги Прочие налоги Акцизный сбор с пачки сигарет Цена: 5,53 долл. США по ППС Общая сумма налогов = 5,30 долл. США по ППС (67,9% от цены за пачку сигарет) Общая сумма налогов = 2,91 долл. США по ППС (58,3% от цены за пачку сигарет) Общая сумма налогов = 3,36 долл. США по ППС (60,8% от цены за пачку сигарет)Общая сумма налогов = 1,18 долл. США по ППС (38,1% от цены за пачку Примечание: Средневзвешенные значения получены на основе оценки ВОЗ числа людей в возрасте 15 лет и старше, куривших сигареты на момент обследования в каждой стране в 2017 году. Цены выражены в долларах по паритету покупательной способности (ППС) или в международных долларах, чтобы учесть различия в покупательной способности в разных странах. Диаграмма составлена на основе данных о цене на самую продаваемую марку сигарет, акцизных сборах и прочих налогах, а также о коэффициентах пересчета по ППС, представленных 53 странами с высоким уровнем дохода, 97 странами со средним уровнем дохода и 28 странами с низким уровнем дохода. Суммы отдельных значений могут не совпадать с общими значениями из-за ошибок при округлении. 0.50 1.91 0.88 2.16 2.50 1.05 4.25 2.06 2.48 0.68 0.86 2.08 0 1 2 3 4 5 6 7 8 СРЕДНЕВЗВЕШЕННАЯ РОЗНИЧНАЯ ЦЕНА И РАЗМЕР НАЛОГОВ (АКЦИЗНЫЙ СБОР И СОВОКУПНЫЙ НАЛОГ) НА САМЫЕ ПРОДАВАЕМЫЕ МАРКИ СИГАРЕТ, 2018 ГОД 108 109ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ИЗМЕНЕНИЕ ЦЕНОВОЙ ДОСТУПНОСТИ СИГАРЕТ, 2008–2018 ГОДЫ Примечание: Изменение ценовой доступности рассчитано по методу наименьших квадратов как темп изменения ВВП на душу населения, необходимого для покупки 2000 сигарет самой продаваемой марки в местной валюте в любой данный год. Подробная информация о расчетах представлена в Техническом примечании III. Цены и налоги на сигареты продолжают расти в странах с высоким уровнем доходов, даже после корректировки по паритету покупательной способности Уровни цен и налогов на сигареты остаются самыми высокими в странах с высоким уровнем дохода, даже с учетом разницы в покупательной способности. Цены на пачку сигарет, совокупные налоги и акцизный компонент налога на табачные изделия как доля от цены за пачку ниже в странах с низким и средним уровнями дохода, при этом средняя процентная доля совокупного налога в цене варьируется от 38% до 58%. Эта доля достигает почти 68% в странах с высоким уровнем дохода, хотя неналоговая часть цен на сигареты примерно одинакова во всем мире. Все страны, особенно страны с низким и средним уровнями дохода, имеют веские основания для дальнейшего повышения своих акцизных сборов, что приведет к снижению ценовой доступности сигарет. Употребление табака не будет должным образом сокращаться, если табачные изделия со временем станут более доступными в ценовом отношении. Когда рост цен не идет в ногу с увеличением доходов на душу населения, табачные изделия становятся более доступными по цене (117, 189). Наблюдение за тенденциями в ценовой доступности сигарет за отчетный период помогает политикам понять, как изменились цены на сигареты по отношению к способности населения их покупать, и может определять рекомендуемые изменения в налоговой политике, чтобы повлиять на уровень цен и эффективно сократить потребление табака. Ценовая доступность сигарет в 2008, 2010, 2012, 2014, 2016 и 2018 годах измерялась внутренним валовым продуктом на душу населения, необходимым для покупки 2000 сигарет самой продаваемой марки, о которой сообщалось в конкретном году. Затем было рассчитано среднее изменение за период 2008–2018 годов. Благодаря этой мере сигареты стали менее доступными по цене в 83 странах и существенно не изменились в этом отношении в 63 странах, в то время как они стали более доступными по цене в 30 странах. Из этих 30 стран 28 были странами с низким и средним уровнями дохода. Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Невозможно рассчитать из-за недостатка данных Сигареты стали более доступными в ценовом отношении Ценовая доступность не изменилась Сигареты стали менее доступными в ценовом отношении 39 13 2 5 6 7 23 58 36 9 13 5 37 23 Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% В 2015 году в рамках продолжающихся усилий страны по реформированию налогового законодательства министры здравоохранения и финансов Колумбии рекомендовали увеличить налоги на сигареты на 200% в период с 2016 по 2017 год, а затем на 150% к 2020 году. Эта рекомендация была направлена на повышение в стране исторически очень низкого уровня налогообложения табачных изделий и получаемых от этого доходов, чтобы он в большей степени соответствовал рекомендациям ВОЗ и уровню налогообложения в других странах региона. Положительные результаты повышения налогов, которое в конечном итоге было одобрено, зависели от многосекторальной группы экспертов и представителей служб общественного здравоохранения из национального и международного гражданского общества, которые вместе боролись с вмешательством табачной промышленности, используя надежные данные и преобразуя их в стратегически жизнеспособные изменения политики. Чтобы опровергнуть аргумент табачной промышленности о том, что повышение налогов приведет к неуправляемому всплеску незаконной торговли табачными изделиями, группы гражданского общества провели первое открытое исследование масштабов незаконной торговли сигаретами в Колумбии и установили, что она составляет лишь небольшую часть (3,5% от всех продаж) в пяти обследованных городах Колумбии. В декабре 2016 года Конгресс Колумбии утвердил 100%-ное повышение акцизов на сигареты и табак промышленного производства, дополнительное повышение на 50% в январе 2018 года и ежегодные корректировки, начиная с января 2019 года, что эквивалентно ежегодному изменению индекса потребительских цен на 4% (195). Это означает, что в январе 2017 года специфический налог на сигареты увеличился в два раза с 700 колумбийских песо за пачку из 20 сигарет до 1400 колумбийских песо, а затем был увеличен до 2100 колумбийских песо в январе 2018 года. По состоянию на 2018 год доля налога на самую продаваемую марку сигарет в Колумбии составляет 78,4% от ее цены, при этом акцизы составляют 62,5% (52,5% — специфические и 10% — адвалорные). Это ставит Колумбию на самый высокий уровень достижений в реализации меры MPOWER по повышению налогов на табачные изделия. Что касается влияния этой меры, то в 2017 году доходы от табачных акцизов увеличились на 54%, а продажи сигарет снизились на 23% по сравнению с 2016 годом. Колумбия в три раза повысила налоги на сигареты в течение двух лет ИЗМЕНЕНИЕ ДЕЙСТВИТЕЛЬНОЙ ЦЕНЫ И ДОЛИ СОВОКУПНОГО НАЛОГА НА ПАЧКУ САМОЙ ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ В КОЛУМБИИ, 2008– 2018 ГОДЫ 2008 2010 2012 Доля совокупного налога на самую продаваемую марку сигарет 2014 2016 2018 1769 1837 2197 2407 2521 3864 Д ей ст ви те ль на я це на з а па чк у из 2 0 си га ре т, в ко лу м би йс ки х пе со (б аз ов ая ц ен а в 20 08 г од у) Д ол я со во ку пн ог о на ло га , в % 34.3% 50.6%49.9% 49.4% 49.5% 78.4% Действительная цена за пачку самой продаваемой марки сигарет, в колумбийских песо, 2008 год Источник: (195) 110 111ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В 2016 году государства-члены Совета сотрудничества арабских государств Персидского залива (ССАГПЗ) договорились ввести акцизный налог на изделия, вредные для человека и окружающей среды, включая табак. До этого соглашения государства- члены ССАГПЗ (Бахрейн, Катар, Кувейт, Объединенные Арабские Эмираты, Оман и Саудовская Аравия) традиционно полагались исключительно на импортные пошлины на табачные изделия, которые в совокупности составляли около 20% от их розничной цены. Новый акцизный налог — это попытка как диверсифицировать источники дохода, так и признать опасность табачных изделий. Саудовская Аравия была первой страной- членом ССАГПЗ, которая в июне 2017 года ввела акцизный налог на табачные изделия промышленного производства, за ней последовали Объединенные Арабские Эмираты в октябре 2017 года и Бахрейн в декабре 2017 года. Катар присоединился к ним в январе 2019 года, и Оман должен повысить акцизный налог в июне 2019 года. Новый акцизный налог унифицирован в странах Персидского залива на уровне 100% от розничной цены табачных изделий без учета налогов и уже оказывает заметное влияние на их цены. Ожидается, что введение налога и последующий рост цен на табачные изделия в этих странах приведут к сокращению потребления табака и, как следствие, к уменьшению бремени связанных с ним болезней. Совет сотрудничества арабских государств Персидского залива вводит акцизы на вредные для здоровья изделия РОЗНИЧНАЯ ЦЕНА САМОЙ ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ, ПО ППС1 ПРОЦЕНТНАЯ ДОЛЯ СОВОКУПНОГО НАЛОГА В ЦЕНЕ САМОЙ ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Катар, 5.21 Кувейт, 5.90 Оман, 7.59 ОАЭ, 9.23 Бахрейн, 10.15 Саудовская Аравия, 17.68 0 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 2008 2010 2012 2014 2016 2018 Ц ен а в до лл ар ах п о П П С за п ач ку и з 20 с иг ар ет 1 Паритет покупательной способности или международные доллары Примечание: Данные на этой диаграмме отражают изменения по состоянию на июль 2018 года и учитывают только повышение налогов в Бахрейне, Саудовской Аравии и Объединенных Арабских Эмиратах. Бахрейн Саудовская Аравия Объединенные Арабские Эмираты 0 10 20 30 40 50 60 70 80 2016 2018 13.3% 16.7% 18.2% 64.5% 68.1% 73.5% Со во ку пн ы й на ло г, % С 2008 года число стран, взимающих высокие табачные налоги, увеличилось практически в два раза: жители почти каждой пятой страны в настоящее время защищены высокими налогами. 112 113ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Национальные программы борьбы против табака: жизненно важные программы для прекращения табачной эпидемии отчитываться перед этим централизованным органом (175). Программы борьбы против табака также должны быть включены в более широкие программы стран в области здравоохранения и развития (196). В крупных странах или странах, федеральные политические системы которых разделяют управляющие полномочия между центральным федеральным органом власти и обладающими законодательной властью региональными или местными политическими единицами, передача полномочий по реализации НПБТ местным органам власти может обеспечить большую гибкость в разработке политики и осуществлении программ и, вероятно, позволит этой политике и программам охватить более широкие слои населения (197). Поскольку многие мероприятия по борьбе против табака проводятся на региональном и местном уровнях (даже когда планирование осуществляется на национальном уровне), руководителям общественного здравоохранения и государственным деятелям на соответствующих субнациональных уровнях необходимы достаточные ресурсы для наращивания устойчивого потенциала по реализации этих мероприятий (94). Национальные программы борьбы против табака должны также обеспечить, чтобы подгруппы населения с непропорционально высокими показателями табачного потребления были охвачены мерами политики и программами, адаптированными к их потребностям (197). Борьба против табака требует активного участия гражданского общества Национальные программы борьбы против табака нуждаются в поддержке не только со стороны партнеров в правительстве, но и со стороны гражданского общества; это, в частности, исключает табачную промышленность и ее союзников, которые не могут быть законными участниками деятельности по борьбе против табака (94). Непрерывное участие соответствующих неправительственных организаций и других групп гражданского общества имеет большое значение для обеспечения дальнейшего прогресса в усилиях по борьбе против табака на национальном и глобальном уровнях (197). Две трети населения мира проживает в странах, где созданы национальные органы по борьбе против табака Каждая четвертая страна в мире имеет национальный орган, отвечающий за достижение целей в области борьбы против табака, обеспеченность кадрами которого составляет не менее пяти штатных сотрудников в пересчете на занятых полное рабочее время. К счастью, поскольку многие из этих стран являются густонаселенными, две трети населения мира находится под защитой такого органа. Еще 117 стран (где проживает одна треть населения мира) работают над достижением целей в области борьбы против табака, имея меньшее число сотрудников (84 страны), или в ситуациях, когда число сотрудников неизвестно (33 страны). Только 17 стран (с общим населением 145 миллионов человек) не имеют национального органа по борьбе против табака, и 14 из них являются странами с низким и средним уровнями дохода. За последние 2 года только три страны расширили свои национальные программы борьбы против табака в достаточной степени, чтобы достичь наивысшего уровня из реализации (Ботсвана, Ирак и Катар), что увеличило охват населения на 44 миллиона человек. В то же время, одна страна опустилась ниже уровня передовой практики: Суринам сократил число сотрудников, полностью занятых только вопросами борьбы против табака. В период после 2008 года еще 15 стран с общим населением 499 миллионов человек создали хорошо укомплектованную кадрами национальную команду, члены которой в течение всего своего рабочего времени заняты только вопросами борьбы против табака. Стоит отметить, что эта мера может недооценивать истинные масштабы реализации НПБТ в странах, поскольку информация об обеспеченности кадрами программ борьбы против табака на национальном уровне является неполной, а формальный механизм сбора этой информации от стран отсутствует. Рамочная конвенция ВОЗ по борьбе против табака настоятельно рекомендует странам создать национальную программу борьбы против табака (НПБТ), чтобы она возглавила усилия каждой страны по борьбе против него. С этой целью Статья 5 РКБТ ВОЗ гласит, что: «Каждая Сторона разрабатывает, осуществляет, периодически обновляет и пересматривает всесторонние многосекторальные национальные стратегии, планы и программы по борьбе против табака … [и] создает или укрепляет и финансирует национальный координационный механизм или координационные органы по борьбе против табака». Кроме того, Статья 26.2 РКБТ ВОЗ устанавливает, что: «Каждая Сторона обеспечивает финансовую поддержку в отношении своей национальной деятельности, направленной на достижение цели настоящей Конвенции» (1). Страны с низким уровнем дохода Страны со средним уровнем дохода Страны с высоким уровнем дохода Данные не представлены Национальный орган по борьбе против табака отсутствует Наличие национального органа, отвечающего за достижение целей в области борьбы против табака, обеспеченность кадрами которого составляет менее пяти штатных сотрудников, или данные о количестве сотрудников не представлены Наличие национального органа, отвечающего за достижение целей в области борьбы против табака, обеспеченность кадрами которого составляет не менее пяти штатных сотрудников 23 58 33 58 11 Д ол я ст ра н (ч ис ло с тр ан у ка за но в ну тр и ст ол бц ов ) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 41 3 2 18 11 3 2 НАЦИОНАЛЬНЫЕ ПРОГРАММЫ БОРЬБЫ ПРОТИВ ТАБАКА ПРОГРЕСС В ОСУЩЕСТВЛЕНИИ НАЦИОНАЛЬНЫХ ПРОГРАММ БОРЬБЫ ПРОТИВ ТАБАКА (2008-2018 ГОДЫ) Децентрализация полномочий по реализации НПБТ имеет крайне важное значение Надлежащим образом финансируемые, четко ориентированные НПБТ или координационные механизмы имеют решающее значение для разработки и поддержания устойчивой политики, которая может обратить вспять табачную эпидемию (1). Министерства здравоохранения или эквивалентные им государственные учреждения должны взять на себя ведущую роль в стратегическом планировании и разработке политики, при этом другие министерства и ведомства должны 2007 2008 2010 2012 2014 2016 2018 4.4 4.7 4.8 4.8 4.9 4.9 42 44 49 55 55 57 Население (миллиарды) Страны Общая численность населения: 7,6 миллиарда человек Общее число стран: 195 Чи сл о ст ра н 0 50 75 100 125 150 175 200 25 0 1 2 3 4 5 6 7 8 За щ ищ ен но е на се ле ни е (м ил ли ар ды ) 114 115ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В 2003 году Ирландия стала первой страной в мире, осуществившей деятельность по созданию среды, свободной от табачного дыма. Однако потребление табака по-прежнему оказывает огромное влияние на жителей Ирландии: ежегодно от болезней, связанных с табаком, умирает не менее 5500 человек. Несмотря на то что страна имеет большой опыт борьбы против табака, а его употребление в течение последних нескольких десятилетий постепенно сокращалось, в 2013 году Ирландия решила довести борьбу против табака до «завершающей фазы», или заключительных этапов достижения Ирландией статуса страны, свободной от табака. Для достижения этой цели в плане содержится 60 рекомендаций по значительному сокращению курения среди взрослого населения до менее 5% к 2025 году. Было подсчитано, что для достижения этой амбициозной цели ежегодно в течение следующих 10 лет более 55 000 нынешних курильщиков должны будут бросать курить. Программа «Ирландия, свободная от табака» была разработана Министерством здравоохранения Ирландии и его Исполнительным органом по вопросам здравоохранения в 2013 году. Эта государственная стратегия (на 2013–2025 годы) направлена на координацию и руководство деятельностью по борьбе против табака в рамках всей системы здравоохранения и включает в себя несколько межправительственных мероприятий, основанных на комплексе мер MPOWER, с целью «денормализации» употребления табака в Ирландии, особенно для следующего поколения жителей. Отчет Ирландии о ходе реализации программы «Ирландия, свободная от табака» за 2017 год свидетельствует о значительном прогрессе, в том числе о принятии законодательства, требующего использования стандартизированной упаковки табачных изделий, и о разработке новой кампании QUIT, которая направлена на усиление поддержки людей, желающих бросить курить. В 2018 году был опубликован разработанный Исполнительным органом по вопросам здравоохранения национальный план действий (на 2018–2021 годы), определяющий стратегическое направление и приоритетные действия, необходимые для достижения целей, поставленных в этом плане. В течение следующих 4-х лет цели программы «Ирландия, свободная от табака», включают в себя уделение приоритетного внимания защите детей во всех инициативах и поощрение «денормализации» употребления табака для будущих поколений; поддержку людей в отказе от употребления табака и лечение табачной зависимости как угрозы их здоровью; а также разработку антитабачного законодательства, обеспечение и контроль его соблюдения. Программа «Ирландия, свободная от табака» Каждая четвертая страна в мире имеет национальный орган, отвечающий за достижение целей в области борьбы против табака, обеспеченность кадрами которого составляет не менее пяти штатных сотрудников в пересчете на занятых полное рабочее время. Кампания в поддержку программы «Ирландия, свободная от табака» Мадагаскар продемонстрировал огромную приверженность и прогресс в борьбе против табака и на сегодняшний день реализовал четыре меры MPOWER на самом высоком уровне. В 2007 году был создан Консультативный комитет по борьбе против табака для поддержки координации деятельности по осуществлению РКБТ ВОЗ во всех секторах. Этот многосекторальный комитет собирается каждые три месяца, в него входят представители целого ряда министерств и организаций гражданского общества, занимающихся вопросами борьбы с употреблением табака. Комитет играет посредническую роль между Министерством здравоохранения и соответствующими органами и предоставляет возможность для эффективного сотрудничества. Например, организации гражданского общества и некоторые департаменты министерства (спорта, национального образования, народонаселения, здравоохранения) сотрудничают в разработке и проведении мероприятий по повышению информированности населения. Комитет также играет контролирующую роль и подает сигнал тревоги в случае несоблюдения нормативных требований и вмешательства со стороны табачной промышленности. Кроме того, при поддержке Министерства внутренних дел в стране постепенно создаются многоотраслевые комитеты в различных регионах страны. Благодаря этим координационным механизмам Мадагаскар продолжает демонстрировать свою приверженность делу борьбы с табачной эпидемией в целях спасения человеческих жизней и повышения благосостояния населения. Многосекторальное сотрудничество способствует ведению борьбы против табака, Мадагаскар Повышение информированности людей во время Всемирного дня без табака в 2018 году, Мадагаскар. 116 117ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Заключение С момента принятия РКБТ ВОЗ в 2003 году в мире был достигнут значительный прогресс. Успешное расширение за последние 10 лет масштабов применения мер MPOWER до уровня передовой практики, принятых в разных странах, независимо от уровня их доходов и численности населения, является свидетельством успешной реализации мер по сокращению спроса на табак, предусмотренных РКБТ ВОЗ. По мере того как страны продолжают работать над созданием и осуществлением эффективных стратегий борьбы против табака, они могут найти поддержку в примерах других стран, которые успешно приняли меры, соответствующие уровню передовой практики. За годы, прошедшие с момента введения комплекса мер MPOWER, нам пришлось столкнуться с большими проблемами. Были и будут неудачи, неожиданно возникающие барьеры, вмешательства табачной промышленности и сложные политические препятствия, которые необходимо преодолеть. Несмотря на эти проблемы, в настоящее время 5 миллиардов человек защищены как минимум одной мерой по борьбе против табака на уровне передовой практики — на 3,9 миллиарда больше, чем в 2007 году. С другой стороны, 2,6 миллиарда человек остаются незащищенными от вреда для здоровья и негативных экономических последствий употребления табака внедрением передовых методов борьбы против него, основанных на фактических данных. Миллионы жизней были спасены с момента введения мер MPOWER, и только благодаря скоординированному вниманию мирового сообщества усилия по борьбе против табака оказались столь успешными. К сожалению, табачная эпидемия еще далека от своего завершения. Хотя употребление табака сократилось в большинстве стран и регионов, рост численности населения означает, что общее число людей, употребляющих табак, остается неизменно высоким. Программы борьбы против табака не всегда выполняются быстро и легко, и все страны могут извлечь выгоду из разработки и обеспечения соблюдения более эффективной политики борьбы против табака. Со времени представления последнего доклада только одна страна — Бразилия — присоединилась к Турции и внедрила все меры MPOWER на самом всестороннем уровне, и лишь несколько других стран приняли более двух мер на уровне передовой практики. Даже в странах, где существуют меры, соответствующие уровню передовой практики, можно многое сделать для усиления их соблюдения и получения максимального эффекта от их применения. Основное внимание в настоящем докладе «Предложение помощи в целях прекращения употребления табака» уделяется мере «О» из комплекса мер MPOWER. Только 23 страны предоставляют услуги по прекращению употребления табака на уровне передовой практики, хотя во многих странах большое число потребителей табака сообщают о своем желании отказаться от его употребления. Тем не менее, прогресс налицо — за время после 2007 года всеобъемлющими услугами по прекращению употребления табака охвачено дополнительно 2 миллиарда человек, и 67 стран находятся всего в одном шаге от предоставления таких услуг. Страны со средним уровнем дохода в период после 2007 года добились наиболее очевидного прогресса в оказании поддержки в прекращении употребления табака в учреждениях первичной медико-санитарной помощи и использовании национальных бесплатных телефонных линий для бросающих курить. Фактические данные свидетельствуют о том, что шансы потребителей табака на успешный отказ от его употребления резко возрастают, если они используют эффективные меры по прекращению курения. Настоящий доклад в соответствии со Статьей 14 РКБТ ВОЗ содержит руководящие указания для стран относительно эффективных услуг по прекращению употребления табака и того, как эти услуги могут быть предоставлены для наилучшего удовлетворения запросов потребителей табака, которые хотят отказаться от его употребления. В странах должны предоставляться как минимум краткие консультации по вопросам прекращения курения всем потребителям табака всякий раз, когда они по какой- либо причине обращаются в учреждение первичной медико-санитарной помощи. Страны должны также обеспечить наличие национальной бесплатной телефонной линии для бросающих курить и мобильного сервиса по отказу от курения (mCessation), чтобы охватить более широкие слои населения. Наконец, предоставление никотинзаместительной терапии с компенсацией затрат на нее поможет увеличить число случаев отказа от употребления табака. Сочетание двух или более из этих подходов еще больше увеличивает шансы на успех в прекращении употребления табака. Даже страны с низким уровнем дохода и ограниченными ресурсами могут начать включать краткие консультации в существующие системы первичной медико- санитарной помощи в качестве одного из первых шагов по развитию своей поддержки в отказе от употребления табака. Краткие консультации в учреждениях первичной медико-санитарной помощи должны быть включены в план всеобщего охвата услугами здравоохранения, чтобы потенциально приносить пользу 80% всех потребителей табака в год. В настоящее время только 18 стран оказывают поддержку в прекращении употребления табака с полной компенсацией затрат в большинстве своих учреждений первичной медико- санитарной помощи, и другие страны должны последовать их примеру. Каждая страна обязана защищать здоровье своих граждан, и все Стороны РКБТ ВОЗ взяли на себя конкретное обязательство проводить строгую политику борьбы против табака, включая оказание эффективных услуг по прекращению употребления табака, в качестве важного средства выполнения своих обязательств по защите здоровья своего населения. За 11 лет, прошедших с начала осуществления контроля за соблюдением мер MPOWER, был достигнут невероятный прогресс, в том числе спасены миллионы человеческих жизней, но это только начало. Чрезвычайно важно, чтобы все мы еще раз подтвердили свою приверженность обеспечению полноценной защиты всех людей в мире от огромного вреда, наносимого табачной эпидемией. 118 119ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Библиографические ссылки 12. Глобальная стратегия по ускорению борьбы против табака: содействие устойчивому развитию путем осуществления РКБТ ВОЗ, 2019-2025 гг. 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(http://apps.who.int/iris/bitstre am/10665/44289/1/9789241563970_eng.pdf, accessed 26 June 2019). 124 125ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ТЕХНИЧЕСКИЕ ПРИМЕЧАНИЯ ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ I Оценка существующих мер политики и их соблюдения ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ II Распространенность употребления табака в государствах-членах ВОЗ ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ III Налоги на табачные изделия в государствах-членах ВОЗ ПРИЛОЖЕНИЯ ПРИЛОЖЕНИЕ I Сводные данные о применении мер MPOWER по регионам ПРИЛОЖЕНИЕ II Лечение табачной зависимости ПРИЛОЖЕНИЕ III Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака ПРИЛОЖЕНИЕ IV Наивысший уровень достижений в реализации отдельных мер борьбы против табака в 100 крупнейших городах мира ПРИЛОЖЕНИЕ V Статус Рамочной конвенции ВОЗ по борьбе против табака ПРИЛОЖЕНИЕ VI Данные о глобальных мерах борьбы против табака ПРИЛОЖЕНИЕ VII Обзор положения дел в странах ПРИЛОЖЕНИЕ VIII Доходы от налогов на табачные изделия ПРИЛОЖЕНИЕ IX Налоги и цены на табачные изделия и их ценовая доступность ПРИЛОЖЕНИЕ X Оценки распространенности курения, стандартизированные по возрасту, 2017 год ПРИЛОЖЕНИЕ XI Представленные странами данные о распространенности курения ПРИЛОЖЕНИЕ XII Картографическое представление данных о глобальных мерах борьбы против табака Приложения VI–XIII доступны в сети Интернет по адресу: http://www.who.int/tobacco/global_report/en/ 126 127ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ I Оценка существующих мер политики и их соблюдения В настоящем докладе представлены итоговые показатели достижений стран по каждой из шести мер MPOWER, и методология, использованная при подсчете каждого показателя, описана в данном Техническом примечании. Для обеспечения последовательности и сопоставимости данных, методология их сбора и анализа, используемая в настоящем докладе, в значительной мере основана на предыдущих изданиях доклада. Некоторые методы, использованные в предыдущих докладах, были, тем не менее, пересмотрены и улучшены в настоящем докладе. Там, где был осуществлен пересмотр, данные из предыдущих докладов были заново проанализированы, поэтому результаты сопоставимы по годам. Источники данных Сбор данных осуществлялся с использованием следующих источников: • Для всех разделов: официальные доклады Сторон РКБТ ВОЗ, представленные Конференции Сторон (КС), и сопроводительная документация.1 • Для M (мониторинг): данные о распространенности табака, не предоставляемые в рамках механизма отчетности КС, были собраны главным образом по линии региональных бюро и страновых офисов ВОЗ. Техническое примечание II содержит дополнительную информацию. • Для P (защита людей от табачного дыма), W (предупреждение об опасностях, связанных с употреблением табака) и E (обеспечение соблюдения запретов на рекламу, стимулирование продажи и спонсорство табачных изделий): исходные законы по борьбе против табака (включая нормативные положения), принятые во всех государствах-членах и касающиеся создания среды, свободной от табачного дыма, мер в отношении упаковки и маркировки, а также рекламы, стимулирования продажи и спонсорства табачных изделий. В тех случаях, когда по состоянию на 31 декабря 2018 года закон был принят, но еще не вступил в силу, соответствующий закон был изучен и данные о нем включены в доклад со сноской: «положение принято, но не реализовано по состоянию на 31 декабря 2018 года». • Для W (средства массовой информации): данные об антитабачных кампаниях в СМИ были получены от государств- членов. Чтобы избежать ненужного сбора данных, ВОЗ провела скрининг антитабачных кампаний в СМИ во всех страновых офисах ВОЗ. В странах, где проводились потенциально успешные кампании в СМИ, были установлены контакты с координационными органами для получения дополнительной информации об этих кампаниях; при этом проводились систематический сбор и регистрация данных о таких кампаниях. • Для O (предложение помощи в целях прекращения употребления табака): данные, не предоставляемые в рамках механизма отчетности КС, были собраны главным образом по линии региональных бюро и страновых офисов ВОЗ. • Для R (повышение налогов на табачные изделия): в рамках регионального сбора данных была собрана информация о ценах на самые продаваемые марки сигарет, самые дешевые марки и премиальные марки. Информация о налогообложении сигарет (и, когда это возможно, наиболее часто используемых других курительных и бездымных табачных изделий) и доходах от налогов на табак была получена из министерств финансов. Техническое примечание III содержит подробное описание используемой методологии. На основании этих источников информации ВОЗ определила значение каждого показателя по состоянию на 31 декабря 2018 года. Отступления от этой даты завершения отчетного периода были сделаны для цен и налогов на табачные изделия (сбор данных завершился 31 июля 2018 года) и для антитабачных кампаний в СМИ (сбор данных завершился 30 июня 2018 года). Проверка достоверности данных Для каждой страны каждый показатель, источником которого было законодательство, оценивался двумя разными экспертами из двух различных бюро ВОЗ, как правило, одним — из штаб-квартиры ВОЗ, и другим — из соответствующего регионального бюро. Любые найденные несоответствия перепроверялись обоими экспертами ВОЗ, участвовавшими в проведении оценки, и третьим экспертом, прежде не участвовавшим в оценке законодательства. Разногласия в толковании законодательства устранялись путем: (i) проверки исходного текста закона; (ii) достижения консенсуса между двумя экспертами, проводившими оценку данных; (iii) попытки получить разъяснения от экспертов или юристов в соответствующей стране, и (iv) учета решения третьего эксперта в случае сохранения разногласий. Данные также проверялись на полноту и логическую согласованность показателей. Утверждение данных Окончательные проверенные данные по каждой стране направлялись соответствующим правительствам для рассмотрения и утверждения. С целью упрощения правительственной оценки, для каждой страны создавалась сводная таблица, которая рассылалась для рассмотрения до завершения работы над базой данных доклада. В случаях, когда национальные органы требовали изменить данные, их запросы рассматривались экспертами ВОЗ согласно как законодательству и/или материалам, так и разъяснениям, предоставленным национальными органами, после чего данные корректировались или оставались без изменений. В случаях, когда национальные органы однозначно не соглашались с оценкой данных, это специально отмечалось в таблицах приложений. Более подробную информацию о процедуре обработки данных можно получить в ВОЗ. Анализ данных Важно отметить, что данные о законодательстве отражают статус законов, принятых до 31 декабря 2018 года, имеющих заявленную дату вступления в силу и не подвергающихся юридическому оспариванию, которое могло бы повлиять на эту дату. Данные из законов, не вступивших в силу до 31 декабря 2018 года, имеют соответствующую сноску. Сводные показатели, разработанные для Доклада ВОЗ о глобальной табачной эпидемии, 2019 г., аналогичны тем, которые использовались для доклада 2017 года. В настоящем докладе представлен анализ прогресса, достигнутого в период с 2016 по 2018 год, а также в период с 2007 по 2018 год, с использованием самой последней оценки ситуации в отношении применения мер MPOWER в каждом году, чтобы результаты были сопоставимы по годам. Для меры R самые ранние сопоставимые данные относятся к 2008 году, а для средств массовой информации данные доступны только за 2010 год. Для расчета изменения процентной доли населения, охваченного каждой стратегией или мерой, с течением времени были использованы оценки численности населения за 2018 год. 2 Использование статического года устраняет эффект роста численности населения при оценке изменений в долгосрочной перспективе. Показатели за предыдущие годы были пересчитаны в соответствии с законодательством и/или материалами, полученными после окончания периода оценки соответствующего доклада, или в соответствии с изменениями в методологии расчета показателей. Все группы стран по уровню дохода, использованные в настоящем докладе, взяты из Классификации стран по уровню дохода Всемирного банка, опубликованной Всемирным банком 1 июля 2018 года.3 Для настоящего доклада группы стран с уровнями дохода выше среднего и ниже среднего объединены в одну группу. Когда итоговые данные о выполнении мер MPOWER по стране или группе населения приводятся в аналитическом разделе настоящего доклада совместно, то в эти итоговые данные входит только осуществление мер борьбы против табака (законодательство об обеспечении бездымной среды, услуги для бросающих курить, предупредительные надписи, запреты на рекламу, стимулирование продажи и спонсорство табачных изделий, а также налоги на табачные изделия). Данные в отношении мониторинга употребления табака и антитабачных кампаний в СМИ приводятся отдельно. Поправки к ранее опубликованным данным Данные за 2016 год, опубликованные в предыдущем докладе, были пересмотрены, и около 3% значений показателей были исправлены. Полный набор данных о мерах MPOWER, пересмотренных за все годы вплоть до 2007 года, доступен в файле Excel на веб-сайте доклада. Мониторинг употребления табака и стратегий профилактики Эффективность национальной системы эпиднадзора за употреблением табака определяется частотой и периодичностью репрезентативных на национальном уровне обследований, проводимых в странах среди молодежи и взрослых. Страны причисляются к высшей категории по показателю «Мониторинг», когда в репрезентативных на национальном уровне обследованиях, охватывающих как молодежь, так и взрослых, соблюдены все нижеследующие критерии: • обследование проведено недавно; • обследование было репрезентативным в отношении населения страны; • аналогичное обследование повторялось в течение последних пяти лет (было периодичным); и • проводился опрос молодежи и взрослого населения посредством популяционных обследований школьников или домашних хозяйств, соответственно. Опросы считались недавними, если они были проведены в течение последних пяти лет. Для целей настоящего доклада это означает 2013 или более поздний год. Опросы считались репрезентативными, только если для обеспечения репрезентативности результатов на национальном уровне был использован научный метод случайной выборки. (Обследования на субнациональном уровне или охватывающие отдельные группы населения, предоставляют, хотя и полезную, но недостаточно полную информацию для принятия мер борьбы против табака в отношении всего населения.) Опросы считались периодическими, если такой же опрос или опрос с использованием тех же или похожих вопросов проводился не реже одного раза в каждые пять лет. Для опросов молодежи и опросов взрослого населения использовались следующие определения: Опросы молодежи: опросы учащихся в возрасте 13–15 лет в школах. Вопросы, задаваемые в ходе обследования, должны обеспечивать получение показателей, согласующихся с теми, которые указаны в вопросниках Глобального опроса о потреблении табака среди молодежи и руководствах к ним. Опросы взрослого населения: популяционные опросы способные обеспечить получение показателей в отношении лиц в возрасте 15-ти лет и старше, согласующихся с теми, которые указаны в вопросниках Глобального опроса взрослого населения о потреблении табака и руководствах к ним. Разбивка по показателю «Мониторинг» приведена ниже. Нет известных или недавних* данных, либо данные не являются недавними* и репрезентативными** Недавние* и репрезентативные** данные по взрослым или по молодежи Недавние* и репрезентативные** данные как по взрослым, так и по молодежи Недавние*, репрезентативные** и периодические*** данные как по взрослым, так и по молодежи * Данные за 2013 год или более поздние. ** Выборка обследования репрезентативна в отношении населения страны. *** Сбор данных проводился не реже одного раза в каждые пять лет. Законодательство об обеспечении бездымной среды Существует широкий перечень мест и учреждений, которые законодательно могут стать зонами, свободными от курения. Законодательство об обеспечении бездымной среды может применяться на национальном или субнациональном уровнях. В докладе содержатся данные о национальном законодательстве, а также 128 129ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД о законодательстве в субнациональных юрисдикциях, где оно имеется, и где национальные законы являются неполными. Оценка субнационального законодательства об обеспечении бездымной среды включает в себя административные образования страны первого уровня, как указано в стандарте ISO3166. Данные, собранные на субнациональном уровне и представленные в Приложении VI, отражают только содержание субнациональных законов. Положения национального законодательства указаны в информационном примечании рядом с данными субнационального уровня. В тех случаях, когда статус законодательства об обеспечении бездымной среды не указан в отношении некоторых или всех субнациональных юрисдикций, мы предполагаем, что в них применяется действующий национальный закон. Законодательство оценивалось с целью определения того, обеспечивают ли законы о бездымной среде создание полной4 и постоянной среды, свободной от табачного дыма, в закрытых помещениях всех учреждений в каждой из восьми следующих категорий общественных мест: • учреждения здравоохранения; • образовательные учреждения, кроме университетов; • университеты; • государственные учреждения; • внутренние служебные и рабочие помещения, не вошедшие ни в одну из категорий; • рестораны или заведения, где подают в основном еду; • кафе, пивные и бары или заведения, где подают в основном напитки; • общественный транспорт. Разбивка по показателю «Законодательство об обеспечении бездымной среды» основана на количестве категорий мест, где курение внутри помещений полностью запрещено. Страны, в которых нет полного запрета на курение, введенного на национальном уровне, но где не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды, отнесены к высшей группе. Разбивка по показателю «Законодательство об обеспечении бездымной среды» приведена ниже. Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) В дополнение к данным, использованным для вышеуказанной разбивки по показателю «Законодательство об обеспечении бездымной среды», другие соответствующие данные, такие как информация о штрафах и обеспечении исполнения законодательства, собраны и представлены в Приложении VI. В некоторых странах, для того чтобы значительно расширить диапазон мест, свободных от табачного дыма, включая рестораны и бары, было политически необходимо предусмотреть в законе исключения, позволяющие выделять помещения, специально предназначенные для курения. Но, вместе с тем, требования к этим помещениям технически настолько сложны и строги, что, как ожидается, выполнить их на практике смогут (если смогут вообще) лишь немногие учреждения. Для того чтобы соответствовать критериям «очень строгие технические требования», закон должен содержать по меньшей мере три из шести следующих характеристик (наличие характеристики 5 или 6 является обязательным). Помещение, специально предназначенное для курения, должно: 1. быть закрытым внутренним помещением; 2. быть оборудовано автоматическими дверями, которые обычно бывают закрыты; 3. не быть проходным помещением для некурящих; 4. быть оборудовано соответствующей механической системой принудительной вентиляции; 5. иметь соответствующее оборудование и функциональные отверстия для удаления воздуха из помещения; 6. в помещении для курения должен поддерживаться более низкий уровень давления, чем в прилегающих зонах, но перепад не должен превышать 5 Па. Те немногие страны, чьи законы предусматривают наличие специально предназначенных для курения помещений, отвечающих очень строгим техническим требованиям, в пяти или более оцененных категориях общественных мест, не были учтены в анализе, приведенном в этом разделе, поскольку законодательство этих стран об обеспечении бездымной среды существенно отступает от рекомендаций, содержащихся в руководящих принципах осуществления Статьи 8 РКБТ ВОЗ. К тому же было сложно получить доказательства того, что применение данного закона привело, как ожидалось, к значительному сокращению числа выделенных для курения помещений в этих странах. Страны, чьи законы предусматривают наличие специально предназначенных для курения помещений, отвечающих очень строгим техническим требованиям, менее чем в пяти из оцененных категорий общественных мест, были разбиты на группы в зависимости от числа категорий общественных мест, полностью свободных от табачного дыма. Лечение табачной зависимости Показатель достижений в лечении табачной зависимости основан на наличии в стране: • никотинзаместительной терапии (НЗТ); • поддержки в отказе от курения; • компенсации затрат на любую из вышеперечисленных услуг; и • национальной бесплатной телефонной службы помощи для бросающих курить. Несмотря на низкую себестоимость создания и эксплуатации телефонной службы помощи для бросающих курить, немногие страны с низким или средним уровнями дохода осуществляют такие программы. Таким образом, наличие национальных бесплатных телефонных служб помощи для бросающих курить является условием присвоения только самой высокой категории. Компенсация затрат на лечение табачной зависимости принимается во внимание при присвоении только двух верхних категорий, учитывая ограниченность национальных бюджетов многих стран с невысоким уровнем дохода. Три верхние категории отражают различные уровни готовности государства обеспечить доступность никотинзаместительной терапии и помощи бросающим курить. Разбивка по показателю «Лечение табачной зависимости» приведена ниже. Данные не представлены Услуги для бросающих курить отсутствуют НЗТ* и/или некоторые услуги для бросающих курить** (и то и другое без компенсации затрат) НЗТ* и/или некоторые услуги для бросающих курить** (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ* и некоторые услуги для бросающих курить** (с компенсацией затрат) * Никотинзаместительная терапия. ** Помощь бросающим курить доступна в любом из следующих мест: в поликлиниках или других учреждениях первичной медико-санитарной помощи, больницах, в кабинете врача, по месту жительства. В дополнение к данным, использованным для разбивки по показателю «Лечение табачной зависимости», другие соответствующие данные, такие как информация о перечнях основных лекарственных средств, имеющихся в странах, и т. д., собраны и представлены в Приложении VI. Для данного издания Доклада ВОЗ о глобальной табачной эпидемии странам были заданы дополнительные вопросы о наличии услуг по прекращению употребления табака. Эти вопросы касались мер политики и руководящих принципов, структурного потенциала и интеграции услуг по прекращению курения в другие подходы к борьбе против табака. Собранные данные представлены в Приложении II. Меры политики и руководящие принципы Национальная стратегия борьбы с табаком: для успешного осуществления национальная стратегия страны должна быть реально действующей. Клинические рекомендации: странам был задан вопрос о наличии национальных клинических руководств по прекращению употребления табака, а также о включении информации о способствующих этому мерах в клинические или лечебные руководства по: • Туберкулезу • Сердечно-сосудистым заболеваниям • Гипертонии • Респираторным заболеваниям • Диабету • Раку • Психическим расстройствам • Заболеваниям полости рта • Заболеваниям репродуктивной системы Ответы, полученные в ходе проведения опроса, были проанализированы и проверены с использованием подтверждающей документации, которая была либо (а) приложена респондентами опроса, либо (b) в соответствующих случаях, найдена в Репозитории документов ВОЗ по неинфекционным заболеваниям. В целях сопоставимости между странами приемлемыми были признаны руководящие принципы только национального уровня. Чтобы считаться приемлемыми, клинические руководства должны были соответствовать следующим двум критериям: • Содержать инструкции или рекомендации в отношении клинической практики, которые помогут практикующим врачам и пациентам оптимизировать медицинское обслуживание. • Однозначно рекомендовать прекращение употребления табака или требовать, чтобы практикующие врачи выясняли и фиксировали факт употребления табака во время беседы с пациентом (например, используя стандартизированную форму или калькулятор риска). Протоколы PEN (пакет основных мероприятий в отношении неинфекционных заболеваний для первичной медико- санитарной помощи в условиях ограниченных ресурсов), региональные (многострановые) руководящие принципы и международные руководящие принципы были приняты вместо руководящих принципов для конкретных стран в тех случаях, когда можно было продемонстрировать их принятие на национальном уровне. Руководства по интегрированной или первичной медико- санитарной помощи, включая руководства для практикующих врачей, также были признаны приемлемыми. Структурный потенциал Странам был задан вопрос о том, регулярно ли они отражают факт употребления табака в медицинских записях (требуется подтверждающая документация), и является ли прекращение употребления табака частью программы подготовки работников служб первичной медико-санитарной помощи. Интеграция услуг по прекращению курения в другие подходы к борьбе против табака Странам был задан вопрос о том, была ли информация о бесплатной телефонной линии для бросающих курить размещена на пачках сигарет или использовалась при проведении антитабачных кампаний в средствах массовой информации за последние 12 месяцев. При этом запрашивалась и проверялась подтверждающая документация. Анализ затрат на никотинозаместительную терапию Данные о ценах на НЗТ были получены от компании Euromonitor, которые включали 56 стран — 37 стран с высоким уровнем дохода и 19 стран со средним уровнем дохода, сгруппированных в соответствии с Классификацией стран по уровню дохода Всемирного банка. Общие затраты были рассчитаны исходя из упрощенной схемы НЗТ продолжительностью 8 недель. На основании рекомендаций экспертов потребность в антиникотиновых средствах на этот период была установлена либо на уровне 56 никотиновых пластырей (один раз в день), либо 532 пластинки жевательной резинки (12 штук в день в течение 4-х недель, 8 штук в день в течение следующих 2-х недель, затем 6 штук в день в течение последних 2-х недель). Размер упаковки, доступный в каждой стране, также учитывался при расчете наименее дорогого варианта НЗТ. Также предполагалось, что люди с более сильной никотиновой зависимостью будут потреблять такое же количество жевательной резинки/пластырей, что и менее зависимые, хотя и будут при этом использовать подходящий вариант НЗТ с более высоким содержанием никотина. Поскольку цены на антиникотиновые средства с разным содержанием никотина одного и того же бренда существенно не различались (<5%), условные затраты были одинаковыми независимо от степени никотиновой зависимости. Для обеспечения сопоставимости между странами общая цена каждого варианта НЗТ была скорректирована с учетом покупательной способности и конвертирована в международные доллары с использованием предполагаемого коэффициента пересчета 130 131ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Простая упаковка табачных изделий (также называемая стандартизированной упаковкой) определяется в руководящих принципах осуществления Статьи 11 РКБТ ВОЗ как мера «для ограничения или запрета размещения на упаковке логотипов, цветов фирменных изображений или пропагандистской информации, за исключением торгового наименования и наименования изделия, изображенных стандартным цветом и гарнитурой». Для того чтобы страна фигурировала в настоящем докладе как страна, внедрившая простую упаковку табачных изделий, требуется соответствие следующим критериям (установленным руководящими принципами осуществления Статьи 13 РКБТ ВОЗ): • упаковка должна быть черно-белой или с двумя другими контрастными цветами в соответствии с требованиями национальных органов; • на упаковке не должно быть ничего, кроме фирменного наименования, наименования изделия и/или наименования изготовителя, информации для контактов и о количестве изделий в упаковке без каких-либо логотипов или других характеристик, помимо предупреждений о вреде для здоровья, налоговых марок и другой установленной правительством информации или маркировки; • на упаковке должен использоваться шрифт предписанного стиля и размера; • упаковка должна быть стандартизированной формы, размера и материалов; • не должно быть никакой рекламы или стимулов для продажи внутри или снаружи упаковки или на отдельных сигаретах и других табачных изделиях. Антитабачные кампании в средствах массовой информации Страны осуществляют деятельность по распространению информации для достижения разнообразных целей, в том числе для улучшения связей с общественностью, привлечения внимания к проблеме, оказания поддержки государственным мерам политики, а также для побуждения людей к изменению их поведения. Для оказания хотя бы минимального воздействия антитабачные информационные кампании, которые являются основными практическими мерами борьбы против табака, должны по ППС, установленного МВФ на 2018 год. Полученные значения сравнивались со стоимостью ежедневного выкуривания самой дешевой пачки сигарет за тот же период времени, что и проведение курса НЗТ, с использованием данных о ценах, представленных для данного доклада. Наконец, были рассчитаны средние арифметические значения для стран, сгруппированных либо по уровню дохода, либо по факту обеспечения компенсации затрат на НЗТ. Предупредительные надписи на упаковке табачных изделий Раздел доклада, в котором проводится оценка законодательства каждой страны в отношении предупреждений о вреде для здоровья, включает следующую информацию о предупреждениях на пачках сигарет: • являются ли предупреждения о конкретном вреде для здоровья обязательными; • предписанный размер предупреждений, в процентном отношении к площади передней и задней сторон пачки сигарет; • присутствуют ли предупреждения на каждой пачке, а также на любой внешней упаковке и в маркировке, используемой в розничной торговле; • указывают ли предупреждения на конкретные виды вредного воздействия употребления табака на здоровье; • являются ли предупреждения крупными, четкими, заметными и легко читаемыми (например, предписывается обязательное использование определенных цветов, стилей и размеров шрифтов); • производится ли периодическая замена предупреждений; • написаны ли предупреждения на основном языке (всех основных языках) страны; • входят ли в состав предупреждений рисунки или пиктограммы. Размеры предупреждений на передней и задней сторонах пачки сигарет были усреднены для расчета процента общей площади поверхности упаковки, на которую нанесены предупреждения. Эта информация была объединена с определенными характеристиками предупреждений для осуществления разбивки по показателю «Предупреждения о вреде для здоровья». Разбивка по показателю «Предупреждения о вреде для здоровья» приведена ниже. Данные не представлены Предупреждения отсутствуют или имеют небольшой размер 1 Предупреждения имеют средний размер 2, но в них отсутствуют некоторые 3 или многие 4 требуемые характеристики 5 ИЛИ предупреждения имеют большой размер6, но в них отсутствуют многие 4 требуемые характеристики 5 Предупреждения имеют средний размер 2 и содержат все требуемые характеристики 5 ИЛИ предупреждения имеют большой размер 6, но в них отсутствуют некоторые 3 требуемые характеристики 5 Предупреждения имеют большой размер 6 и содержат все требуемые характеристики 5 1 Средний размер предупреждений на передней и задней сторонах упаковки составляет менее 30%. 2 Средний размер предупреждений на передней и задней сторонах упаковки составляет от 30 до 49%. 3 От одной до трех. 4 Четыре или более. 5 Требуемые характеристики: • предупреждения о конкретном вреде для здоровья являются обязательными; • наличие предупреждений на каждой пачке, а также на любой внешней упаковке и в маркировке, используемой в розничной торговле; • указание конкретных видов вредного воздействия употребления табака на здоровье; • предупреждения должны быть крупными, четкими, заметными и легко читаемыми (например, предписывается обязательное использование определенных цветов, стилей и размеров шрифтов); • предупреждения должны периодически меняться; • предупреждения должны включать в себя рисунки или пиктограммы; • предупреждения должны быть написаны на основном языке (всех основных языках) страны. 6 Средний размер предупреждений на передней и задней сторонах упаковки составляет не менее 50%. В дополнение к данным, использованным для разбивки по показателю «Предупреждения о вреде для здоровья», другие соответствующие данные, такие как наличие на упаковке номера телефонной службы помощи для бросающих курить, требование использования простой упаковки табачных изделий, и т. д., собраны и представлены в Приложении VI. мы предполагаем, что в них применяется действующий национальный закон. Достижения стран в области запрета на рекламу, стимулирование продажи и спонсорство табачных изделий были оценены исходя из того, распространялись ли запреты на следующие виды рекламы: • национальное телевидение и радио; • местные журналы и газеты; • рекламные щиты и наружная реклама; • пункты продажи (внутри помещений); • бесплатное распространение табачных изделий по почте или другими способами; • рекламные скидки; • нетабачные изделия, ассоциируемые с табачными фирменными наименованиями (расширение бренда);5 • использование фирменных наименований нетабачных изделий применительно к табачным изделиям (одновременное использование бренда);6 • показ (скрытая реклама) табачных брендов или изделий на телевидении и/ или в кино; • спонсорство (взносы и/или придание огласке взносов). Первые четыре из перечисленных видов рекламы считаются «прямой» рекламой, а остальные шесть считаются «косвенной» рекламой. Полные запреты на рекламу, стимулирование продажи и спонсорство табачных изделий обычно начинаются с запретов на прямую рекламу в национальных СМИ, и затем распространяются на запреты на косвенную рекламу, а также стимулирование продажи и спонсорство. Основное различие между двумя низшими группами заключается в том, распространяются ли запреты на национальное телевидение, радио и печатные СМИ или нет; включение в остальные группы было основано на том, насколько всесторонне закон накладывает запрет на другие виды прямой и косвенной рекламы, включенные в опросный лист. В тех случаях, когда в законе четко не говорилось о трансграничной рекламе, считалось, что реклама как на внутреннем, так и на международном уровне была под запретом только тогда, когда она была полностью запрещена на национальном уровне. Разбивка по показателю «Запреты на рекламу, стимулирование продажи и спонсорство» приведена ниже. Страны, где не менее 90% населения охвачено субнациональным законодательством, иметь определенные особенности: необходимо, чтобы они были достаточно продолжительными и направленными на эффективную поддержку приоритетных мер борьбы против табака, включающих в себя повышение уровня знаний, изменение социальных норм, содействие прекращению курения, профилактику потребления табака, а также усиление поддержки эффективных мер антитабачной политики. Учитывая это, и в соответствии с определением «антитабачные кампании в СМИ», данном в последнем докладе, приемлемыми для анализа были признаны только те кампании в СМИ, которые: (i) были разработаны для поддержки усилий по борьбе против табака; (ii) продолжались не менее трех недель и (iii) осуществлялись в период с 1 июля 2016 года по 30 июня 2018 года. Для обеспечения возможности логистических действий и межстранового сравнения, приемлемыми считались кампании, проведенные только на национальном уровне. В соответствии с последним докладом и для достижения большей точности, необходимо было представлять и проверять материалы о проведении кампаний на основе критериев соответствия для всех стран. Кампании, удовлетворяющие этим критериям, оценивались по следующим характеристикам, подразумевающим использование комплексного подхода к передаче информации: 1. Кампания являлась частью комплексной программы борьбы против табака. 2. До начала кампании было проведено новое или пересмотрено предыдущее исследование для получения полного представления о целевой аудитории. 3. Рекламно-информационные материалы были предварительно испробованы на целевой аудитории и доработаны в соответствии с целями кампании. 4. Приобретение эфирного времени (радио, телевидение) и/или места для размещения печатной рекламы (рекламные щиты, объявления в печатных СМИ и т. д.) осуществлялось путем покупки или получения за счет внутренних ресурсов самой организации, либо внешним специалистом по рекламе или агентством (эта информация позволяет выяснить, использует ли кампания тщательное планирование рекламного бюджета и правильный закупочный процесс для результативного и экономически эффективного охвата своей целевой аудитории). 5. Привлеченное агентство проводило работу среди журналистов, чтобы кампания приобрела известность и была отражена в новостях. 6. Была осуществлена оценка эффективности хода проводимой кампании. 7. Была проведена оценка конечных результатов проводимой кампании. 8. Кампания выходила в эфир на телевидении и/или радио. Разбивка по показателю «Кампании в СМИ» приведена ниже. Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио Запреты на рекламу, стимулирование продажи и спонсорство табачных изделий В докладе содержатся данные как о национальном законодательстве, так и о законодательстве в субнациональных юрисдикциях. Оценка субнационального законодательства в отношении запретов на рекламу, стимулирование продажи и спонсорство табачных изделий включает в себя административные образования страны первого уровня, как указано в стандарте ISO3166. Данные, собранные на субнациональном уровне и представленные в Приложении VI, отражают только содержание субнациональных законов. Положения национального законодательства указаны в информационном примечании рядом с данными субнационального уровня. В тех случаях, когда статус законодательства в отношении запретов на рекламу, стимулирование продажи и спонсорство табачных изделий не указан для некоторых или для всех субнациональных юрисдикций, 132 133ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД полностью запрещающим рекламу, стимулирование продажи и спонсорство табачных изделий, отнесены к высшей группе. Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные (но не на все) виды прямой* и/или косвенной** рекламы Запрет на все виды прямой* и косвенной** рекламы (или не менее 90% населения, охваченного полными субнациональными запретами на рекламу, стимулирование продажи и спонсорство табачных изделий) * Запреты на прямую рекламу охватывают: • национальное телевидение и радио; • местные журналы и газеты; • рекламные щиты и наружную рекламу; • пункты продажи (внутри помещений). ** Запреты на косвенную рекламу охватывают: • бесплатное распространение табачных изделий по почте или другими способами; • рекламные скидки; • нетабачные изделия и услуги, ассоциируемые с табачными фирменными наименованиями (расширение бренда); • использование фирменных наименований нетабачных изделий применительно к табачным изделиям (одновременное использование бренда); • показ (скрытую рекламу) табачных брендов или табачных изделий на телевидении и/или в кино; • спонсорство (взносы и/или придание огласке взносов). В дополнение к данным, использованным для разбивки по показателю «Запреты на рекламу, стимулирование продажи и спонсорство», другие соответствующие данные, такие как запрет на продажу через Интернет или выкладку табачных изделий в пунктах продажи, собраны и представлены в Приложении VI. Налоги на табачные изделия Страны разбиты на группы в соответствии с процентной долей всех табачных налогов в розничной цене пачки из 20 сигарет самой популярной марки. Оценивались такие налоги, как акцизный сбор, налог на добавленную стоимость (иногда называемый «НДС»), импортная пошлина (когда сигареты были импортированы) и любые другие взимаемые налоги. В странах с различным размером налогов на сигареты в зависимости от их длины, произведенного количества или типа (например, с фильтром или без фильтра), в расчет бралась налоговая ставка только на самый популярный бренд. В случае отсутствия информации о чистой прибыли в розничной и оптовой торговле в конкретной стране или в отношении конкретной марки сигарет, эта прибыль считалась равной нулю (за исключением данных, предоставленных национальным статистическим центром). Разбивка по показателю «Налоги на табачные изделия» приведена ниже. Подробная информация представлена в Техническом примечании III. Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены Тенденции изменения ценовой доступности самой продаваемой марки сигарет Ценовая доступность сигарет была рассчитана как процентная доля ВВП на душу населения, необходимая для покупки 2000 сигарет самой популярной марки, о которой сообщалось во всех предыдущих докладах с 2008 года по настоящее время. Годовые темпы роста ценовой доступности, рассчитанные по методу наименьших квадратов, вычислялись путем подгонки линии тренда линейной регрессии к логарифмическим значениям показателя ценовой доступности. Разбивка по показателю «Ценовая доступность» приведена в верхней части нижеследующего столбца. Подробная информация представлена в Техническом примечании III. ДА Сигареты менее доступны в ценовом отношении — ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился. НЕТ Сигареты более доступны в ценовом отношении — ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился. С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет. … Недостаточно данных для анализа тенденций изменения ценовой доступности Национальные программы борьбы против табака Классификация национальных программ борьбы против табака основывается на наличии в странах национального органа, ответственного за достижение целей в области борьбы против табака. Страны, где в национальном органе, ответственном за достижение целей в области борьбы против табака, работает не менее пяти сотрудников в пересчете на занятых полное рабочее время, попадают в высшую группу. Разбивка по показателю «Национальные программы борьбы против табака» приведена ниже. Данные не представлены Национальный орган по борьбе против табака отсутствует Наличие национального органа, отвечающего за достижение целей в области борьбы против табака, который вообще не обеспечен кадрами, или обеспеченность кадрами которого составляет менее пяти штатных сотрудников в пересчете на занятых полное рабочее время Наличие национального органа, отвечающего за достижение целей в области борьбы против табака, обеспеченность кадрами которого составляет не менее пяти штатных сотрудников в пересчете на занятых полное рабочее время Оценка соблюдения законодательства Соблюдение национального и субнационального всеобъемлющего законодательства об обеспечении бездымной среды, а также запретов на рекламу, стимулирование продажи и спонсорство оценивалось группой, в состав которой входили до пяти национальных экспертов, которые определили уровень соблюдения в этих двух областях, как «минимальный», «умеренный» или «высокий». Эти пять экспертов были отобраны в соответствии со следующими критериями: • лицо, ответственное за профилактику употребления табака в министерстве здравоохранения страны, или высшее должностное лицо в правительстве, отвечающее за борьбу против табака или с заболеваниями, связанными с его потреблением; • глава авторитетной неправительственной организации, занимающейся борьбой против табака; • профессиональный медицинский работник (например, врач, медсестра, фармацевт или стоматолог), специализирующийся на заболеваниях, связанных с потреблением табака; • сотрудник факультета общественного здравоохранения в университете; • координатор борьбы против табака в страновом офисе ВОЗ. Эксперты проводили свои оценки самостоятельно. Средние баллы рассчитывались ВОЗ на основе пяти независимых оценок: два балла присваивалось за высокий уровень соблюдения мер политики, один балл — за умеренный уровень, и ноль баллов — за минимальный уровень соблюдения мер политики, т. е. всего от этих пяти экспертов можно было получить не менее 0 и не более 10 баллов. Оценка соблюдения проводилась в отношении законов, принятых до 1 апреля 2018 года. Для стран, принявших законы в более поздний срок, в графе о соблюдении законодательства указано «не применяется». Соблюдение законодательства в отношении создания среды, свободной от табачного дыма, не оценивалось в случаях, когда закон предусматривал наличие специально предназначенных для курения помещений, отвечающих очень строгим техническим требованиям. 1. Стороны отчитываются об осуществлении ими Рамочной конвенции ВОЗ по борьбе против табака в соответствии со Статьей 21. Целью отчетности является предоставление Сторонам возможности обмениваться опытом в осуществлении РКБТ ВОЗ. Доклады Сторон являются также основой для оценки осуществления ими РКБТ ВОЗ Конференцией Сторон. В соответствии с механизмом отчетности, утвержденным КС, Стороны представляют свои первоначальные доклады через два года после вступления в силу РКБТ ВОЗ для этой Стороны, а затем каждые последующие три года. Начиная с 2012 года, все Стороны отчитываются в одно и то же время, один раз в два года. Дополнительная информация доступна в сети Интернет по адресу: http://www.who.int/fctc/ reporting/en/ 2 Департамент ООН по экономическим и социальным вопросам, Отдел народонаселения, «Мировые демографические перспективы: редакция 2017 года» (медиана прогнозируемой величины рождаемости на 2018 год). Дополнительная информация доступна в сети Интернет по адресу: https://population.un.org/wpp/ Download/Standard/Population/. 3 Всемирный банк: показатели мирового развития, опубликованные 1 июля 2018 года. Дополнительная информация доступна в сети Интернет по адресу: https://datahelpdesk.worldbank.org/knowledgebase/ articles/906519-world-bank-country-and-lending-groups. 4 Термин «полная» используется в данном докладе в том смысле, что курение запрещено во всех местах, за исключением мест постоянного проживания и внутренних помещений, выступающих в роли мест длительного постоянного пребывания, таких как тюрьмы, а также медицинские и социальные учреждения длительного пребывания, например психиатрические больницы и дома престарелых. Вентиляция и выделение любых помещений и/или зон, специально предназначенных для курения, не защищают от вредного воздействия вторичного табачного дыма, и только законы, предписывающие полный запрет на курение во всех общественных местах, обеспечивают такую защиту. 5 Когда законодательство не устанавливало явным образом запрет на отождествление нетабачных изделий с табачными фирменными наименованиями (расширение бренда) и не давало определения рекламы и стимулирования продажи табачных изделий, считалось, что расширение бренда находилось под существующим запретом всех форм рекламы и стимулирования продажи в случае, когда страна являлась Стороной РКБТ ВОЗ, предполагая при этом, что применялись определения, содержащиеся в РКБТ ВОЗ. 6 Когда законодательство не устанавливало явным образом запрет на использование фирменных наименований нетабачных изделий применительно к табачной продукции (одновременное использование бренда) и не давало определения рекламы и стимулирования продажи табачных изделий, считалось, что одновременное использование бренда находилось под существующим запретом всех форм рекламы и стимулирования продажи в случае, когда страна являлась Стороной РКБТ ВОЗ, предполагая при этом, что применялись определения, содержащиеся в РКБТ ВОЗ. Оценки соблюдения законодательства представлены в Приложении VI. В Приложении I эти сведения суммированы. Баллы оценки соблюдения законодательства указаны отдельно от разбивки по группам (т. е. соблюдение законодательства не учитывается при расчете разбивки на группы). 134 135ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ II Распространенность употребления табака в государствах-членах ВОЗ Мониторинг распространенности употребления табака играет ключевую роль в усилиях по борьбе с глобальной табачной эпидемией. Достоверные данные о распространенности употребления табака, позволяющие судить о масштабе глобальной табачной эпидемии и влияющих на нее факторах, дают информацию, необходимую для планирования, внедрения и оценки воздействия мер по борьбе против табака. Настоящий доклад содержит данные обследований в отношении распространенности курения 1 и употребления бездымного табака среди молодежи и взрослых (Приложение XI). В нем также представлены смоделированные ВОЗ стандартизированные по возрасту расчетные показатели распространенности употребления табака среди лиц в возрасте 15 лет и старше (Приложение X). В данном техническом примечании содержится информация о методе, использованном ВОЗ для получения расчетных показателей распространенности употребления табака. Источники информации Для проведения анализа были использованы следующие источники информации (в тех случаях, когда официальные отчеты о проведенных обследованиях, объясняющие формирование выборки, методологию и подробные результаты, не были общедоступны, государствам-членам было предложено их предоставить): • информация об опросах, предоставленная Сторонами Секретариату РКБТ ВОЗ; • информация, собранная с помощью опросов ВОЗ, касающихся потребления табака, проведенных под эгидой Глобальной системы эпидемиологического надзора за потреблением табачных изделий — в частности, Глобального опроса взрослого населения о потреблении табака (GATS); • информация, касающаяся потребления табачных изделий, собранная с помощью других исследований ВОЗ, включая исследования с применением поэтапного подхода ВОЗ к эпиднадзору и Всемирное обследование здоровья; • другие системные исследования, проведенные другими организациями, включая, например, Демографические и медико-санитарные обследования (ДМСО) и Кластерное обследование по многим показателям (МИКС); и • расширенный поиск через региональные бюро и страновые офисы ВОЗ с целью выявить страновые опросы, не являющиеся частью международных систем эпиднадзора, такие как Национальное обследование факторов риска в Аргентине или Обследование в отношении неинфекционных заболеваний на Маврикии. Информация, полученная с помощью опросов, проведенных в период после 1990 года, использовалась для целей данного анализа, если она: • была официально признана национальным органом здравоохранения; • включала случайную выборку участников, репрезентативную в отношении населения в целом; • представляла сводные данные странового исследования в отношении одного или нескольких из шести определений употребления табака: число потребляющих табак ежедневно, число потребляющих табак на момент обследования, число курящих ежедневно, число курящих на момент обследования, число курящих сигареты ежедневно и число курящих сигареты на момент обследования: • предоставляла данные о распространенности курения в разбивке по возрастным группам и половой принадлежности. Приведенные выше показатели наиболее полно отражают ситуацию с употреблением табака в разных странах и при этом минимизируют исключение стран из дальнейшего анализа из-за отсутствия надлежащих данных. Несмотря на имеющиеся различия в типах табачных изделий, используемых в разных странах, а также выращенных или произведенных в разных регионах мира, данные по этим шести показателям имеются в большинстве стран, что позволяет проводить надежный статистический анализ.2 Вышеуказанная информация хранится в Глобальном банке данных ВОЗ по борьбе против табака и вместе с исходным кодом, используемым ВОЗ для получения расчетных показателей распространенности курения, публикуется вместе с настоящим докладом по адресу: http://www.who.int/tobacco/. Анализ и представление показателей распространенности употребления табака Метод оценки Статистическая модель, основанная на отрицательной биномиальной мета- регрессии Байеса, использовалась для моделирования приблизительных скорректированных и стандартизированных по возрасту оценок для стран по каждому показателю (употребление табака на момент оценки и ежедневное употребление табака, табакокурение на момент оценки и ежедневное табакокурение, а также курение сигарет на момент оценки и ежедневное курение сигарет) отдельно для мужчин и для женщин. Тенденция считалась статистически значимой, если апостериорная вероятность увеличения или уменьшения была больше 0,75. Подробное описание метода представлено в рецензированной статье в журнале The Lancet, том 385, № 9972, стр. 966–976 (2015). После того как показатели распространенности по результатам национальных обследований были объединены в набор данных, модель была пригодна для расчета оценок тенденций по шести указанным выше показателям. Модель состоит из двух основных компонентов: (а) корректировка недостающих показателей и возрастных групп, и (b) использование регрессии для получения оценки тенденций с течением времени, а также доверительного интервала вокруг оценки. В зависимости от полноты собранных той или иной страной данных опроса модель может использовать данные по другим странам для заполнения информационных пробелов. Страны с пробелами в данных «заимствуют информацию» из «априорных данных», рассчитанных на основе их данных, объединенных с данными из стран того же субрегиона ООН3. Различия в возрастных группах, охваченных каждым из опросов Результаты обследований по отдельным странам иногда указывались по целому ряду возрастных групп. В тех случаях, когда данные по любой возрастной группе в диапазоне от 15 лет и старше отсутствовали, для оценки возрастной структуры употребления табака модель использовала имеющиеся данные из других опросов, проведенных в стране. По возрастным группам, в отношении которых обследования в стране не проводились, к данным страны была применена средняя возрастная структура, наблюдаемая в странах того же субрегиона ООН. Различия в измеренных показателях употребления табака Аналогичным образом, при проведении опросов страны могут указывать различные показатели (например, показатель «курение на момент опроса» в одном обследовании и «ежедневное курение» в другом, или «табакокурение» в одном обследовании и «курение сигарет» в другом). Если по какому-либо показателю данные отсутствовали, для оценки отсутствующей информации модель использовала доступные данные из других обследований, проведенных в стране. В отношении показателей, по которым страна никогда не предоставляла отчетности, к данным страны были применены средние зависимости, наблюдаемые в странах того же субрегиона ООН Смоделированные результаты Модель использовалась для всех стран, в которых опросы соответствовали критериям включения. Результаты для стран с недостаточным количеством данных обследования (например, только одно обследование с подробной разбивкой по возрасту распространенности употребления табака для обоих полов) не были представлены. Результатом использования модели является набор линий тренда для каждой страны, который суммирует данные о распространенности употребления табака, начиная с 2000 года и до самого последнего обследования, и прогнозирует тенденции до 2030 года. Страны с небольшим количеством обследований будут иметь больше заимствованной информации, включенной в их линию тренда, чем страны с большим количеством обследований. В настоящем докладе тенденции на страновом уровне были обобщены в виде средних тенденций для стран с высоким, средним и низким уровнями дохода, а также в среднем по миру. Представлены тенденции с 2007 по 2017 год с прогнозами тех же линий тренда до 2030 года. Прогноз предполагает, что темпы и уровень принятия новых мер политики в течение периода, охватываемого обследованиями в стране, останутся неизменными. В будущем, когда страны примут более жесткую политику борьбы против табака и проведут новые обследования, пересчитанные линии тренда будут отражать эти изменения. В настоящем докладе представлены сопоставимые оценки текущей распространенности курения табака среди людей в возрасте 15 лет и старше по всем странам за один год (2017). Эти показатели взяты из линии тренда для каждой страны на 2017 год. Показатели сопоставимы, поскольку модель стандартизировала результаты обследований, как описано выше, а затем стандартизировала их по возрасту, как описано ниже. При расчете средних показателей распространенности употребления табака в глобальном масштабе и в группах стран с разными уровнями дохода по классификации Всемирного банка, для стран, где не проводилась оценка, использовались средние показатели, исходя из предположения о том, что их показатели распространенности являются средними показателями в субрегионе ООН, к которому эти страны относятся.3 Стандартизированные по возрасту показатели распространенности употребления табака Сравнение общих показателей распространенности между двумя и более странами в определенный момент времени или в одной стране, но в разные моменты времени может быть неточным при наличии существенной разницы в возрастном распределении или потреблении табака в зависимости от половой принадлежности двух сравниваемых популяций. Метод стандартизации по возрасту часто используется для решения этой проблемы и позволяет провести корректное сравнение распространенности употребления табака между странами, после того как все описанные выше вопросы, относящиеся к проведению сравнения, были решены. Метод предусматривает применение разбитых по половой принадлежности повозрастных показателей в каждой популяции по отношению к одной стандартной популяции (в настоящем докладе используется стандартное население ВОЗ — вымышленное население, возрастное распределение которого в значительной степени отражает возрастную структуру стран с низким и средним уровнями дохода). Итоговый стандартизированный по возрасту показатель относится к числу курильщиков на 100 человек стандартного населения по определению ВОЗ. В результате показатели, полученные с помощью этой процедуры, являются лишь гипотетическими числами, не имеющими внутреннего содержания. Они имеют значение только при сравнении показателей, полученных из разных стран. Сравнение с оценками распространенности курения, представленными в предыдущих изданиях данного доклада. Оценки, приведенные в настоящем докладе, согласуются между собой, но не с оценками, подготовленными для более ранних изданий доклада. Хотя метод оценки остается прежним, обновленный набор данных за период 1990–2018 годов является гораздо более полным. Например, со времени выпуска Доклада ВОЗ о глобальной табачной эпидемии, 2017 г. к набору данных были добавлены 242 национальных обследования из 89 стран, а 46 существующих обследований были обновлены дополнительными значениями показателей. Каждый раунд оценок ВОЗ рассчитывается с использованием всех имеющихся данных обследований, начиная с 1990 года. Чем больше значений показателей доступно, тем более надежными являются оценки тенденций. Таким образом, каждый раунд улучшает ранее опубликованные оценки, и следует использовать оценки только последнего раунда. Хотя оценки на страновом уровне в настоящем докладе относятся только к 2017 году, весь ряд тенденций с 2000 по 2025 год опубликован в двухгодичном Глобальном докладе ВОЗ о тенденциях в курении табака на 2000–2025 годы. 1 Курение табака включает в себя сигареты, сигары, трубки, наргиле, кальяны, водяные трубки, изделия из нагреваемого табака и любые другие виды курительного табака. 2 Мы опубликовали эти данные по странам, представившим данные о распространенности употребления бездымного табака. 3 Полный список стран по субрегионам ООН представлен на страницах с ix по xiii публикации Мировые демографические перспективы: редакция 2017 года, выпущенной Департаментом по экономическим и социальным вопросам ООН и размещенной по адресу: https://population. un.org/wpp/Publications/Files/WPP2017_Volume-I_ Comprehensive-Tables.pdf (по состоянию на 17 апреля 2019 года). Следует обратить внимание, что для целей анализа употребления табака были внесены следующие коррективы: (i) субрегион Восточной Африки был разделен на два региона: Острова Восточной Африки и Остальная часть Восточной Африки; (ii) Азербайджан, Армения, Грузия, Казахстан, Кыргызстан, Латвия, Литва, Таджикистан, Туркменистан, Узбекистан и Эстония были отнесены к Восточной Европе; (iii) Израиль, Кипр и Турция были отнесены к Южной Европе; (iv) Центральная Африка и Южная Африка были объединены в один субрегион; v) субрегионы Меланезии, Микронезии и Полинезии были объединены в один субрегион; и (vi) Ирландия и Соединенное Королевство были отнесены к Северной Америке. 136 137ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Настоящий доклад включает в себя приложения, содержащие сведения о доле совокупного налога и акцизов в цене самой продаваемой марки сигарет, основанные на полученной от каждой страны информации о налоговой политике. Это примечание содержит информацию о методологии, использованной ВОЗ для оценки доли совокупного налога и акцизов на табачные изделия в цене за пачку из 20 сигарет на основании представленных странами данных. Оно также содержит информацию о дополнительных данных, собранных для подготовки настоящего доклада, относительно налогообложения табачных изделий. 1. Сбор данных Все данные были собраны ВОЗ в период с июня 2018 года по январь 2019 года в рамках регионального сбора данных. При расчете доли совокупного налога и акцизных сборов двумя основными вводными составляющими были: (1) цены и (2) налоговые ставки и структура налогообложения. Была собрана информация о ценах на самые продаваемые марки сигарет, самые дешевые марки и премиальные марки по состоянию на июль 2018 года. Данные о структуре налогообложения были получены из министерств финансов. Достоверность этой информации была проверена с помощью других источников. Для многих стран это было сделано благодаря проведенной большой работе и знаниям, накопленным ВОЗ с 2009 года во время прямых контактов с министерствами финансов при обсуждении вопросов налогообложения табачных изделий. Другие источники, в том числе документы по налоговому законодательству, постановления, официальные данные о налоговых ставках и структуре налогообложения, а также коммерческая информация (при наличии ТЕХНИЧЕСКОЕ ПРИМЕЧАНИЕ III Налоги на табачные изделия в государствах- членах ВОЗ 1. Специфические акцизы Специфический акцизный сбор – это налог на определенный вид товара, произведенного для продажи внутри страны или ввезенного и проданного в этой стране. Как правило, налог взимается с производителя или, в дополнение к импортным пошлинам, в пункте ввоза товара в страну импортером. Эти налоги взимаются в виде суммы с каждой сигареты, пачки сигарет, 1 тысячи сигарет или 1 килограмма. Пример: 1,50 доллара США с пачки из 20 сигарет. 2. Адвалорные акцизы Адвалорный акциз является налогом на определенный вид товара, произведенного для продажи внутри страны или ввезенного и проданного в этой стране. Как правило, налог взимается с производителя или, в дополнение к импортным пошлинам, в пункте ввоза товара в страну импортером. Эти налоги рассчитываются в виде процента от стоимости сделки между двумя независимыми организациями в какой-либо точке цикла производства/распространения; адвалорные акцизы, как правило, зависят от стоимости сделки между производителем и розничным/оптовым продавцом. Пример: 60% от цены производителя. 3. Импортные пошлины Импортная пошлина представляет собой налог на определенный вид товара, ввезенного в страну для потребления в этой стране (т. е. товар не идет транзитом в другую страну). Как правило, импортные пошлины взимаются с импортера в пункте ввоза товара в страну. Эти налоги могут зависеть либо от объема, либо от стоимости. Импортные пошлины, зависящие от объема, как правило, применяются таким же образом, как и акцизные сборы, зависящие от объема. Импортные пошлины, зависящие от стоимости, как правило, применяются к стоимости поставки на условиях СИФ (стоимость, страхование, фрахт), т. е. стоимости невыгруженной партии товара, которая включает в себя стоимость самого товара, страхование, транспортировку и разгрузку. Пример: 50%-ая импортная пошлина взимается с поставки на условиях СИФ. 4. Налог на добавленную стоимость и налог с продаж Налог на добавленную стоимость (НДС) является «многоступенчатым» налогом на все потребительские товары и услуги, применяемым пропорционально цене продукта, уплаченной потребителем. Хотя производители и оптовики также участвуют в администрировании и уплате налога на всем протяжении цикла производства/распространения, их расходы возмещаются через систему налоговых кредитов, так что конечный потребитель является единственным, кто платит в итоге. Большинство стран, применяющих НДС, используют налогооблагаемую базу, которая включает в себя любые акцизные сборы и таможенные пошлины. Пример: НДС составляет 10% от розничной цены. Однако некоторые страны вместо этого применяют налоги с продаж. В отличие от НДС, налоги с продаж взимаются в пункте розничной продажи с общей стоимости приобретенных товаров и услуг. Для целей настоящего доклада были приняты меры для обеспечения расчета доли НДС и/или налога с продаж в соответствии с правилами, существующими в конкретных странах. 5. Прочие налоги Также была собрана информация о любых других налогах, которые не являются акцизным сбором, НДС или налогом с продаж, но применяются в отношении либо количества табака, либо стоимости сделки с табачными изделиями. Эта информация была собрана максимально подробно с указанием того, что облагается налогом, а также того, как рассчитывается налоговая база. таковой) были получены либо в рамках регионального сбора данных, либо загружены с веб-сайтов министерств или из других баз данных, например МВФ или Всемирного банка. Основное внимание в собранных данных о налогообложении уделено косвенным налогам на табачные изделия (например, различным видам акцизных сборов, импортным пошлинам, налогу на добавленную стоимость), которые обычно оказывают наибольшее влияние на цену табачных изделий. Среди косвенных налогов наиболее важными являются акцизные сборы, поскольку они применяются исключительно к табаку и вносят наибольший вклад в существенное увеличение цен на табачные изделия и, как следствие, в сокращение употребления табака. Таким образом, налоговые ставки, общие суммы и сфера применения акцизов являются главной составной частью собранных данных. Ряд других налогов, в частности, прямые налоги, такие как налоги на доходы корпораций, потенциально могут оказывать столь сильное влияние на цены табачных изделий, что производители перекладывают эти налоги на плечи конечных потребителей. Тем не менее, ввиду трудности сбора информации по этим налогам и сложности единообразной оценки их потенциального влияния на ценообразование в разных странах, здесь они не рассматриваются. В представленной слева таблице описываются виды налогов. 2. Анализ данных Стоимость самой продаваемой марки сигарет учитывалась при расчете размера налога как доли в розничной цене, указанной в Приложении I и таблице 9.1 Приложения IX. В странах, где размер налога на сигареты зависит от их длины, произведенного количества или типа (например, с фильтром или без фильтра), в расчет бралась соответствующая налоговая ставка только на самую продаваемую марку сигарет. В случае Канады и США расчетные средние национальные оценки цен и налогов, отражают тот факт, что каждый штат/ провинция применяет различные налоговые ставки помимо действующего федерального налога. В случае Бразилии, где в разных штатах действуют разные ставки НДС, была использована самая высокая ставка, которая применяется в большинстве штатов. В Федеративных Штатах Микронезии, которые также применяют разные ставки НДС в разных штатах, была использована ставка НДС, применяемая в том штате, где осуществлялся сбор данных о ценах, а именно Понпеи. Для Китая были рассчитаны средневзвешенная розничная цена и налог, учитывая очень большое количество брендов, продаваемых на рынке: самый продаваемый бренд, меняющийся почти каждый год и представляющий очень небольшую долю рынка, не был репрезентативным. Импортная пошлина использовалась при расчете доли налога только в том случае, если в страну ввозилась самая продаваемая марка сигарет. Импортная пошлина не учитывалась при расчете совокупного налога в странах, где самый продаваемый бренд (даже международный) был местного производства. В тех случаях, когда импортируемые сигареты ввозились из страны, с которой было заключено двустороннее или многостороннее торговое соглашение, освобождающее от уплаты пошлины, были приняты меры для обеспечения того, чтобы импортная пошлина не учитывалась при расчете взимаемых налогов. «Прочие налоги» — это все другие косвенные налоги, не указанные как акцизы, импортные пошлины или НДС. Эти налоги, тем не менее, расценивались как акцизы, если они имели специальную ставку на табачные изделия. 3. Расчет Обозначим долю налогов в цене широко потребляемой марки сигарет (пачка из 20 сигарет или эквивалент) как Sts. Тогда:, Sts = Sas + Sav + Sid + SVAT j где: Sts = совокупная доля налогов в цене пачки сигарет; Sas = доля специфических акцизных сборов (или эквивалента) в цене пачки сигарет; Sav = доля адвалорных акцизов (или эквивалента) в цене пачки сигарет; Sid = доля импортных пошлин в цене пачки сигарет (если самый популярный бренд импортируется); SVAT = доля налога на добавленную стоимость в цене пачки сигарет. Расчет Sas довольно прост и заключается в делении величины специфического акцизного сбора с пачки из 20 сигарет на общую цену. В отличие от Sas, расчет доли адвалорных акцизов Sav значительно более сложен и требует некоторых допущений, которые описаны ниже. Импортные пошлины могут рассчитываться как по количеству, так и по стоимости. Поэтому Sid рассчитывается так же, как Sas, если расчет производится по количеству, и так же как Sav, если он производится по стоимости. Ставки НДС, указанные странами, обычно применяются к розничным ценам, не включающим в себя НДС, но иногда и к ценам, включающим в себя НДС. SVAT рассчитывается для соответствующего отражения доли НДС в розничной цене, включающей в себя НДС. Цена пачки сигарет может быть выражена следующим образом: P = [(M + M×ID) + (M + M×ID) × Tav% + Tas + π] × (1 + VAT%) или P = [M × (1×ID) × (1+Tav%) + Tas + π] × (1 + VAT%) k где: Например, Таиланд отнес налог на продажу табака и алкоголя, предназначенный для целевого финансирования Тайского фонда укрепления здоровья, к категории «прочие налоги». Однако, поскольку этот налог введен только на табачную и алкогольную продукцию, он действует как акциз, и поэтому в расчетах он учитывался как акциз. Следующим шагом было приведение всех налогов к единой налоговой базе — в нашем случае это розничная цена, включающая в себя налог с оборота (далее P). Как показывает пример в таблице, стандартизация налоговых баз важна для правильного расчета доли налога. Страна B применяет такую же ставку адвалорного налога (20%), что и страна A, но в конечном итоге имеет более высокий уровень налогообложения и более высокую конечную цену, так как налог взимается на более позднем этапе реализации продукции. Сравнение представленных установленных законом ставок адвалорного налога без учета этапа, на котором он взимается, может привести к необъективным результатам. Аналогичная методология использовалась для расчета доли налога в цене самого распространенного, по сообщению каждой из стран, типа курительных (отличных от сигарет) и бездымных табачных изделий. Расчет цены изделия проводился из расчета за 20 грамм любого курительного табака или бездымных табачных изделий, за исключением сигар и сигарилл, по которым как цена, так и налог указывались за штуку. Цена и налог на табачные изделия для курения (включая биди, сигары с обрезанными концами, сигариллы, сигары, трубочный табак, табак для самокруток или водяных трубок) были рассчитаны для 70 стран, а расчет в отношении бездымных табачных изделий (жевательного табака, сухого и влажного нюхательного табака или снюса) был проведен для 27 стран (см. таблицу 9.6 Приложения IX в Интернете). Цена и налог на изделия из нагреваемого табака (за 20 стиков) также были рассчитаны, но только для очень небольшого числа стран, которые сообщили о таких изделиях (девять стран). СТРАНА A (US$) СТРАНА B (US$) [A] Цена производителя (одинаковая в обеих странах) 2,00 2,00 [B] Страна A: адвалорный налог с цены производителя (20%) = 20% x [A] 0,40 - [C] Чистая прибыль розничных и оптовых продавцов (одинаковая в обеих странах) 0,20 0,20 [D] Страна B: адвалорный налог с цены розничного продавца (20%) = 20% x [E] - 0,55 [E] Конечная цена = P = [A] + [B] + [C] или [A] + [C] + [D] 2,60 2,75 Доля совокупного налога (в % от P) 0,40/2,60 = 15,4% 0,55/2,75 =20% 138 139ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД P = цена за пачку из 20 сигарет самого популярного бренда, потребляемого в стране; M = цена производителя/дистрибьютора или импортная цена, если бренд импортируется; ID = ставка импортной пошлины (там, где это применимо) на пачку из 20 сигарет;1 Tav = установленная ставка адвалорного акциза; Tas = специфический акциз на пачку из 20 сигарет; π = прибыль розничного продавца, оптовика и импортера с пачки из 20 сигарет (иногда выраженная в виде наценки); VAT = установленная ставка налога на добавленную стоимость с цены без учета НДС. Эта формула корректировалась с учетом конкретных условий в стране, таких как налоговые базы адвалорного налога и акциза, существование (или отсутствие) адвалорных и специфических акцизов, а также того, являлся ли самый популярный бренд сигарет производимым в стране или импортируемым. Во многих случаях (особенно в странах с низким и средним уровнями дохода) налоговой базой для расчета адвалорного акциза была цена производителя/дистрибьютора или стоимость поставки на условиях СИФ. Но на самом деле налогооблагаемая база адвалорного налога сильно различается по всему миру и может включать в себя другие налоговые базы, такие как розничная цена, розничная цена без учета некоторых налогов (и/или некоторых заранее определенных наценок), розничная цена без учета всех налогов и т. д. Зная цену (M) и величину специфического акциза (Tas), легко рассчитать долю Sas (= Tas/P). Ситуация с адвалорными налогами (и, где это применимо, Sid) довольно проста, когда по закону налоговой базой является розничная цена (как в некоторых странах Европейского союза). Расчет усложняется, когда розничная цена не является налоговой базой, потому что для расчета величины адвалорного налога необходимо знать налоговую базу (M). В большинстве случаев значение M было неизвестно (за исключением случаев, когда страна специально предоставляла эти данные), поэтому его необходимо было вычислить. Используя уравнение (2), можно определить значение M: P 1 + VAT% M = (1 + Tav%) x (1 + ID) l π, или чистая прибыль оптовых и розничных продавцов редко разглашается публично и варьируется в разных странах. При расчете M для наиболее популярных брендов отечественного производства мы принимали значение π за ноль (т. е. = 0), поскольку чистая прибыль розничных и оптовых продавцов предполагалась малой. Однако установление величины прибыли, равной нулю, приводит к завышению M и, соответственно, налогооблагаемой базы адвалорного налога. Это, в свою очередь, приводит к завышению размера адвалорного налога. Поскольку цель данного расчета заключается в определении того, насколько велика доля налогов на табачные изделия в цене обычной пачки сигарет, предположение о том, что чистая прибыль розничных/оптовых продавцов (π) равна нулю, не ставит страны в невыгодное положение, занижая значение их адвалорных налогов. Учитывая это, было решено, что до тех пор, пока информация по конкретной стране не будет представлена в ВОЗ, чистая прибыль розничных/оптовых продавцов от продажи брендов местного производства будет считаться равной нулю. В тех странах, где самая популярная марка сигарет импортируется, импортная пошлина взимается со стоимости поставки на условиях СИФ, а последующие акцизы — с налогооблагаемой базы, включающей в себя стоимость поставки на условиях СИФ и импортную пошлину, но не прибыль импортера. Для сигарет местного производства цена производителя включает в себя его собственную прибыль, которая автоматически включается в M. Однако на практике прибыль импортера может быть довольно значительной, и установление ее величины равной нулю (как в случае сигарет местного производства) приводит к значительному завышению M, и тем самым к завышению доли адвалорного налога в конечной цене. По этой причине значение M для импортируемых изделий рассчитывалось иначе: M* (или стоимость поставки на условиях СИФ) рассчитывалась либо на основании информации, предоставленной странами, либо с использованием дополнительных источников (информации из базы данных Comtrade2 Организации Объединенных Наций). M* обычно рассчитывалась как импортная цена сигарет в стране (стоимость импорта, деленная на количество импортируемых сигарет для страны-импортера). Однако в исключительных случаях, когда такие данные отсутствовали (Демократическая Республика Конго, Ливия и Экваториальная Гвинея), вместо этого учитывались экспортные цены (когда экспортная цена считалась слишком низкой — то есть ниже 0,2 доллара США за упаковку — стоимость поставки на условиях СИФ была приблизительно рассчитана как экспортная цена плюс 10 центов США). После чего адвалорный и другие налоги были рассчитаны таким же образом, как и для сигарет местного производства, используя M* вместо M в качестве налогооблагаемой базы там, где это было применимо. Что касается НДС, в большинстве случаев за основу принималась P без учета НДС (или цена производителя/дистрибьютора плюс все акцизы). Другими словами: SVAT = VAT% × (1 — SVAT), что равнозначно m SVAT = VAT% ÷ (1+ VAT%) Однако в некоторых случаях нам сообщали, что НДС не собирался должным образом на всех уровнях цепи поставок и взимался в основном на этапах импортирования или производства. В этом случае НДС рассчитывался на основе M (или M*) и различных налогов, взимаемых на этом этапе, — в основном импортных пошлин и акцизов (Ангола, Бенин, Вануату, Вьетнам, Габон, Гамбия, Гвинея-Бисау, Иран, Кабо- Верде, Камерун, Кирибати, Кот-д’Ивуар, Мавритания, Мали, Острова Кука, Суринам, Тонга, Тувалу, Уганда, Экваториальная Гвинея и Эфиопия). В сумме налоговые ставки рассчитываются следующим образом: Sts = Sid + Sas + Sav + SVAT n Sas = Tas ÷ P Sav = (Tav% × M) ÷ P или (Tav% × M*× (1+ Sid)) ÷ P 3 если самый популярный бренд был импортирован Sid = (TID% × M*) ÷ P (если импортная пошлина является зависимой от стоимости) или ID ÷ P (если импортная пошлина взимается как определенная сумма за пачку) SVAT = VAT% ÷ (1+ VAT%) 4. Цены Первичный сбор данных о ценах для этого и предыдущих докладов включал в себя обследование розничных торговых точек. Сбор данных о ценах осуществлялся следующим образом: • В дополнение к информации о самой продаваемой марке сигарет, о которой сообщалось в предыдущие годы, сборщикам данных было предоставлено время, чтобы сообщить о новом наиболее продаваемом бренде, в случае если бренд, указанный в прошлые годы, больше не являлся самым продаваемым. • По каждой торговой марке были затребованы данные о ценах в двух - π -Tas различных типах розничных торговых точек. В анкеты, разосланные сборщикам данных, были предварительно занесены наименования самых продаваемых в каждой стране брендов. Популярный бренд был определен на основании данных, собранных в ходе анкетирования в 2016 году, данных из дополнительного источника (Euromonitor 4) и данных, предоставленных ВОЗ министерствами финансов в рамках тесного сотрудничества. В тех странах, где подобные данные были недоступны, сборщикам данных было предложено указать наименования популярных брендов и их цены. Два типа розничных торговых точек были определены следующим образом: 1. Супермаркет/гипермаркет: сеть или независимые торговые точки с торговой площадью более 2500 квадратных метров и основным акцентом на продажу продуктов питания/напитков/ табачных изделий и других бакалейных товаров. Гипермаркеты также продают ряд непродовольственных товаров. 2. Киоск/газетный киоск/табачный киоск/отдельный продовольственный магазин: маленькие удобные магазины, розничные торговые точки, торгующие преимущественно продуктами питания, напитками и табачными изделиями или их сочетанием (например, киоск, газетный киоск или табачный киоск), либо широким спектром преимущественно бакалейных товаров (отдельный продовольственный магазин или отдельная небольшая бакалейная лавка). Самые продаваемые бренды использовались последовательно на протяжении времени, чтобы наиболее полно отразить изменения в ценах. Однако в некоторых случаях, когда считалось, что рыночная доля первоначально использовавшегося бренда существенно изменилась, этот бренд заменялся на новый, более распространенный бренд. В 2018 году изменения в отношении бренда были внесены для Австралии, Азербайджана, Антигуа и Барбуды, Барбадоса, Белиза, Бенина, Боснии и Герцеговины, Бразилии, Вьетнама (другой бренд, но та же ценовая категория), Габона, Гамбии, Гренады, Казахстана, Кипра, Кубы, Мозамбика (более дорогой бренд), Нигера, Никарагуа, Пакистана, Папуа-Новой Гвинеи, Перу, Сальвадора, Сент-Винсента и Гренадин, Сербии, Таиланда (более дешевый бренд) и Туркменистана (невозможно определить, как новый бренд сравнивался с предыдущим). В 11 других странах (Австрия, Боливия (Многонациональное Государство), Венгрия, Дания, Испания, Науру, Панама, Польша, Румыния, Словакия и Швеция) бренд, представленный в 2018 году, был вариантом бренда, представленного в 2016 году, и они рассматривались как идентичные для целей сравнения цен. Как и в 2012, 2014 и 2016 годах, цена, использованная для каждой из 28 стран Европейского союза (ЕС)5, была ценой самого продаваемого бренда, собранной ВОЗ. До 2012 года информация о ценах и налогах полностью бралась из отчетов, опубликованных на веб-сайте Еврокомиссии по налогообложению и таможенному союзу ЕС. Цена, используемая ЕС в предыдущие годы для расчета ставки налога, была самой популярной ценовой категорией (MPPC), которая предполагалась равной ценовой категории самого продаваемого бренда, указанного в данном докладе. Однако, начиная с 2011 года, ЕС рассчитывает и указывает налоговые ставки на основе средневзвешенной цены (WAP), и, следовательно, информация о MPPC больше не была легкодоступна для стран ЕС. Поэтому для того чтобы соответствовать оценкам прошлых лет и для обеспечения возможности сравнения между странами, в 2012 году ВОЗ решила собрать из первых рук информацию о ценах на самый продаваемый бренд (на основе информации о структуре рынка табачных изделий, полученной из дополнительных источников) для расчета ставок налога. Данные о ставках акцизов и НДС по-прежнему собираются из таблиц, опубликованных ЕС. Однако это означает, что доли налогов, вычисленные и представленные здесь, не обязательно будут совпадать с публикуемыми ЕС значениями. В основном это связано с расчетом ставок специфического акциза как процента от розничной цены, которые будут меняться в зависимости от использованной цены. Более подробная информация о разнице в цене и доле налогов для стран ЕС представлена в таблице слева. Общая доля налогов (% от розничной цены) Розничная цена (20 сигарет) Страна По оценкам ВОЗ По данным ЕС MSB по данным ВОЗ WAP по данным ЕС Валюта Австрия 75,3% 78,53% 5,50 4,76 EUR Бельгия 77,0% 79,37% 6,60 5,88 EUR Болгария 83,6% 85,09% 5,20 5,02 BGN Венгрия 72,3% 75,22% 1 245,00 1 118,72 HUF Германия 68,3% 72,49% 6,40 5,64 EUR Греция 81,2% 85,64% 4,60 4,10 EUR Дания 74,1% 79,89% 44,50 40,16 DKK Ирландия 78,4% 89,12% 12,20 10,07 EUR Испания 78,2% 79,28% 5,00 4,52 EUR Италия 76,0% 77,13% 5,50 4,76 EUR Кипр 74,4% 75,67% 4,50 4,28 EUR Латвия 80,0% 83,99% 3,50 3,20 EUR Литва 73,8% 79,46% 3,75 3,18 EUR Люксембург 68,3% 69,40% 5,30 4,60 EUR Мальта 77,6% 79,40% 5,50 5,25 EUR Нидерланды 71,8% 78,29% 7,00 6,19 EUR Польша 76,8% 80,04% 15,50 13,82 PLN Португалия 71,7% 76,16% 5,00 4,47 EUR Румыния 68,6% 72,56% 17,50 15,86 RON Словакия 77,1% 77,88% 3,30 3,23 EUR Словения 79,2% 81,28% 3,70 3,51 EUR Соединенное Королевство Великобритании и Северной Ирландии 79,4% 88,80% 9,40 7,81 GBP Финляндия 87,4% 88,67% 7,22 6,70 EUR Франция 82,4% 85,07% 8,00 6,81 EUR Хорватия 78,8% 79,91% 25,00 23,93 HRK Чешская Республика 75,4% 78,31% 94,00 86,00 CZK Швеция 68,4% 74,16% 65,00 57,94 SEK Эстония 79,4% 85,82% 4,25 3,55 EUR Сравнение цен и общей доли налогов на табачные изделия проведено на основе данных обследования ВОЗ о самом продаваемом бренде (MSB) и данных ЕС о средневзвешенной цене (WAP). Примечание: Оценки ВОЗ относятся к данным о ценах на самый продаваемый бренд, собранным в июле 2018 года. Показатели и данные о средневзвешенных ценах, собранные и представленные ЕС, также относятся к июлю 2018 года. Как указывалось ранее, данные о самом продаваемом бренде использовались для всех стран ЕС, за исключением Финляндии, которая напрямую отчиталась перед ВОЗ о своей средневзвешенной цене (WAP) за 2008, 2010, 2012, 2014, 2016 и 2018 годы. Данные 2018 года по Финляндии показывают разницу между WAP, представленной в ВОЗ, и WAP по данным ЕС. Это связано с тем, что данные о цене, представленные в ВОЗ, были обновлены в 2019 году, в то время как данные о WAP, представленные ЕС, были собраны в 2018 году. 140 141ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД 5. Факторы, которые необходимо учитывать при интерпретации изменений доли налогов Изменение размера налога как доли в цене зависит не только от изменений налога, но и от изменений самой цены. Таким образом, несмотря на увеличение размера налога, доля налога может остаться неизменной или снизиться; аналогичным образом, иногда доля налога может увеличиться, несмотря на отсутствие изменения размера налога или даже его снижение. В текущей базе данных есть случаи увеличения налога в период с 2016 по 2018 год, когда доля налога, выраженная в процентном отношении к цене, снизилась. В основном это связано с тем, что в абсолютном выражении рост цены был выше увеличения налога (особенно в случае увеличения специфического акцизного сбора). Например, в Монголии специфический акциз увеличился с 3480 тугриков за 100 сигарет в 2016 году до 3830 тугриков за 100 сигарет в 2018 году (увеличение на 10%), при этом цена самого продаваемого бренда выросла с 1700 до 2000 тугриков за пачку (увеличение на 18%). Что касается доли налогов, в 2016 году акцизный сбор составлял 52,9% от цены и снизился до 47,4% от цены в 2018 году. Это обусловлено тем, что цены выросли в большей степени, чем налоги. Точно так же есть случаи, когда увеличение (уменьшение) налога как доли в цене было нивелировано факторами, не имеющими прямого отношения к налоговым ставкам. В текущей базе данных это было связано с одной или несколькими из следующих причин: • В некоторых случаях цена увеличилась без изменения величины налога, что привело к уменьшению доли специфического или смешанного акциза (например, Германия, Дания, Доминика, Израиль, Йемен, Кипр, Китай, Мексика, Палау, Польша, Сент- Винсент и Гренадины, Тимор-Лешти, Тунис, Швейцария и Эквадор). • В других случаях цены выросли в большей степени, чем налоги, что привело к уменьшению доли специфического или смешанного акциза (например, Австрия, Алжир, Венгрия, Гамбия, Гондурас, Гренада, Доминиканская Республика, Иордания, Иран (Исламская Республика), Исландия, Испания, Канада, Коста-Рика, Литва, Люксембург, Мальта, Монголия, Норвегия, Объединенная Республика Танзания, Острова Кука, Португалия, Республика Молдова, Румыния, Самоа, Сейшельские Острова, Сербия, Словакия, Соединенное Королевство Великобритании и Северной Ирландии, Соединенные Штаты Америки, Суринам, Тонга, Тринидад и Тобаго, Турция, Уганда, Украина, Чешская Республика, Чили, Швеция, Ямайка). • В случае с импортными товарами стоимость поставки на условиях СИФ является внешней переменной, которая также влияет на расчет доли налога. Это имеет значение в странах, где адвалорный налог рассчитывается от стоимости поставки на условиях СИФ, или когда НДС рассчитывается на основании стоимости поставки на условиях СИФ плюс акциз, а не розничной цены без учета НДС. Например, при неизменных других факторах, в случае увеличения стоимости поставки на условиях СИФ увеличивается налоговая база, что ведет к более высокому проценту налога. К странам, в которых произошли изменения доли налогов в основном из-за изменения стоимости поставки на условиях СИФ, относятся Ливия, Микронезия (Федеративные Штаты) и Того. • Кроме того, необходимо также обратить внимание на страны, в которых в период с 2016 по 2018 год произошла смена самого продаваемого бренда сигарет. Это также повлияло на долю специфического или смешанного акциза в этих странах. В некоторых случаях из-за того, что новый бренд был более дорогим и, несмотря на повышение налогов, общая доля налогов уменьшалась (Босния и Герцеговина, Мозамбик и Перу). В случае Сальвадора доля налогов уменьшилась, несмотря на отсутствие изменений налогов, из-за очевидного роста цен за счет появления новой, более дорогой марки сигарет, указанной как самый продаваемый бренд. В другом случае (Белиз) новый бренд стал дешевле, поэтому доля налогов увеличилась, несмотря на отсутствие повышения налогов. Наконец, в расчеты налоговых ставок за 2008, 2010, 2012, 2014 и 2016 годы были внесены соответствующие поправки на основании предоставленной новой, более качественной информации о налогах и ценах в ряде стран. 6. Дополнительная налоговая информация (см. таблицу 9.3 Приложения IX в Интернете) Важным выводом, который подчеркивается в настоящем докладе, является то, что для оценки степени эффективности налоговой политики необходимо учитывать множество аспектов налогообложения табачных изделий. Налог как доля от цены не дает полной картины эффективности налоговой политики. В целях изучения других аспектов налоговой политики, для настоящего доклада с 2015 года ведется сбор дополнительной информации, касающейся налогообложения табачных изделий, и она представлена в виде данных, которые могут шире информировать ученых и политиков о налоговых стратегиях в разных странах. Информация в настоящем докладе собрана и сгруппирована по двум основным темам: структура/ уровень налогообложения и налоговое администрирование. Также была собрана информация по странам, резервирующим налоги на табачные изделия для целевого финансирования программ здравоохранения и/или мероприятий по борьбе против табака. Различные блоки данных/показателей, представленные по каждой из этих тем, были разработаны и подтверждены на основе фактических данных, представленных в предыдущих докладах. I. Структура/уровень налогообложения a. Процентная доля акциза в цене: более высокие ставки акциза и бо́льшая опора на акциз являются более предпочтительными b. Тип применяемого акциза: является ли акциз специфическим, адвалорным, смешанным или не применяется вообще. c. Единая или многоуровневая система акцизного налогообложения: единый акциз проще в администрировании, чем многоуровневая система, при которой используются разные ставки налогообложения на одно и тоже табачное изделие в зависимости от заданных критериев (это не относится к странам, где не взимается акцизный налог). d. Применяет ли страна специфический акциз или смешанную систему, опираясь в большей степени на специфический компонент налогообложения (более 50% совокупного акциза — специфический компонент): специфические акцизы обычно ведут к более высоким ценам и меньшему ценовому разрыву между брендами, поэтому такие акцизы является более эффективными (это не относится к странам, где применяется только адвалорный акциз или вообще не используется акцизное налогообложение). e. Является ли взимаемый акциз адвалорным или смешанным, и существует ли минимальный специфический налог. Минимальный налог защищает от занижения стоимости табачных изделий. Он также приводит к росту цен, так как цена не может быть ниже уплачиваемого налога (эта категория не относится к странам, где применяется только специфический акциз или вообще не используется акцизное налогообложение). f. Налогооблагаемая база адвалорного налога в странах, которые применяют адвалорную или смешанную систему акцизного налогообложения. Адвалорные налоги, рассчитываемые относительно розничной цены или розничной цены за вычетом НДС, более просты в администрировании. Розничную цену проще определить, чем цену производителя или стоимость поставки на условиях СИФ, что уменьшает риск занижения оценки (это не относится к странам, где применяется только специфический акциз или вообще не используется акцизное налогообложение). g. Является ли взимаемый акциз специфическим или смешанным, и проводится ли автоматическая корректировка специфического компонента налогообложения с учетом инфляции (или других факторов). Если специфический акциз с течением времени не корректируется с учетом инфляции (или другого показателя, такого как уровень дохода), его воздействие будет ослаблено. Желательно, чтобы он корректировался автоматически (эта категория не относится к странам, где применяется только специфический акциз или вообще не используется акцизное налогообложение). h. Политика минимальных цен: хотя это и не считается передовой практикой, было сочтено важным сообщить о странах, которые действительно установили минимальные цены на табачные изделия в рамках своей политики акцизного налогообложения. i. Разброс цен: доля цены самого дешевого бренда в цене премиального бренда (цена самого дешевого бренда ÷ цена премиального бренда × 100). Чем выше процентная доля, тем меньше разрыв, и тем меньше возможностей для замещения более дешевыми брендами. II. Налоговое администрирование а. Требование наличия акцизных марок (или фискальных марок) на табачных изделиях: акцизные марки помогают налоговым органам обеспечивать соблюдение требований уплаты налогов производителями и импортерами, а также выявлять нелегальные табачные изделия. Страны были уведомлены о том, что акцизные марки должны иметь особые элементы, помимо тех, которые присутствуют на традиционных бумажных марках. В частности, такие кодированные акцизные марки имеют уникальные идентификаторы, используемые для выявления наличия нелегальных табачных изделий. Были собраны данные для определения того, в каких странах на марках присутствуют дополнительные элементы, позволяющие отслеживать и прослеживать такие изделия. b. Беспошлинная продажа сигарет: в большинстве стран в магазинах беспошлинной торговли в аэропортах, в международных транспортных средствах и/или в других магазинах беспошлинной торговли табачные изделия продаются без акцизов (и других косвенных налогов, таких как НДС и импортные пошлины). Беспошлинные табачные изделия обычно продаются путешественникам, выезжающим из страны, но теперь они также доступны и для тех, кто въезжает в страну. Запрет на беспошлинную продажу сигарет для личного потребления снижает вероятность того, что эти продукты попадут на нелегальный рынок. Кроме того, нет никаких оснований для беспошлинной продажи смертельно опасной продукции; эти недополученные налоги являются потерей дохода для государства. Некоторые страны уже приняли меры и запретили беспошлинную продажу табачных изделий. Эти изделия все еще можно найти в аэропортах и других магазинах беспошлинной торговли, но они продаются с включенными в их стоимость акцизными налогами. III. Целевое ассигнование (часть налогов или поступлений от налогов, выделяемая на здравоохранение и/или борьбу против табака). Налоги могут служить источником значительного объема доходов. Одним из способов устранения негативных внешних последствий употребления табака могло бы стать повышение налогов с целью сокращения потребления табака и финансирования здравоохранения, которое часто недофинансируется и подвергается существенной нагрузке из-за потребления табака населением (см. таблицу 9.3 Приложения IX в Интернете). 7. Оценки ценовой доступности сигарет (см. таблицу 9.5 Приложения IX в Интернете) Ценовая доступность сигарет в 2008, 2010, 2012, 2014, 2016 и 2018 годах измерялась внутренним валовым продуктом на душу населения, необходимым для покупки 2000 сигарет самой продаваемой марки, о которой сообщалось в конкретном году. Анализ ценовой доступности сигарет в настоящем докладе дает следующую информацию: • Индекс ценовой доступности (% ВВП на душу населения, необходимый для покупки 2000 сигарет): более высокое значение индекса в разных странах указывает на то, что сигареты там сравнительно дороже по отношению к доходам населения. • Стали ли сигареты относительно более доступными по цене за период с 2008 по 2018 год (изменение индекса ценовой доступности, как указано выше): по мере снижения ценовой доступности сигарет сокращается их потребление. Оценки ВВП на душу населения в единицах местной валюты были взяты из базы данных МВФ «Перспективы развития мировой экономики» (WEO), которая содержит полный ряд оценок для большинства из 195 стран, по которым были представлены данные. В тех случаях, когда данные о ВВП на душу населения отсутствовали в базе данных WEO (Андорра, Куба, оккупированная палестинская территория, включая Восточный Иерусалим, и Сомали), использовались ряды данных Всемирного банка о ВВП на душу населения. В случае Островов Кука использовались государственные данные. Для каждой пары «страна-год» валюта, указанная для самого продаваемого бренда, была пересчитана в соответствующую валюту для получения ряда данных о ВВП, и при необходимости были выполнены конверсии и корректировки обменных курсов (Беларусь, Замбия, Камбоджа, Латвия, Либерия, Литва, Туркменистан и Эстония) для выравнивания двух рядов данных. Чтобы оценить, изменилась ли ценовая доступность сигарет в среднем с 2008 года, ее среднегодовое процентное изменение было рассчитано по методу наименьших квадратов как ее темп роста для всех стран с данными за четыре или более лет, включая данные за 2018 год. Этот критерий автоматически исключал страны, где использовались оценки ВВП на душу населения Всемирного банка, учитывая, что на момент проведения анализа ряд оценок закончился 2017 годом. Ценовая доступность сигарет оценивалась как неизменная, если рассчитанное по методу наименьших квадратов изменение ВВП на душу населения, необходимого для покупки 2000 сигарет (то есть 100 пачек по 20 сигарет), не было статистически значимым при уровне 5%. Сигареты считались в среднем менее (более) доступными в ценовом отношении, если рассчитанное по методу наименьших квадратов изменение ВВП на душу населения, необходимого для покупки 2000 сигарет, было положительным (отрицательным) и статистически значимо отличалось от нуля при уровне 5%. 1 Импортные пошлины могут меняться в зависимости от страны происхождения в случаях преференциальных торговых соглашений. ВОЗ пыталась определить происхождение табачной упаковки и обоснованность использования таких ставок налога, когда это было возможно. 2 https://comtrade.un.org/ 3 Или Sav = (Tav % × M*) ÷ P, если адвалорный налог применялся только к стоимости поставки на условиях СИФ, а не к стоимости СИФ + импортная пошлина. 4 Паспорт компании Euromonitor International, 2018 год. 5 За исключением Финляндии, где использовалась средневзвешенная цена сигарет за 2008, 2010, 2012, 2014, 2016 и 2018 годы. 142 143ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В Приложении I содержится обзор отдельных мер борьбы против табака. По каждому региону ВОЗ представлены обзорные таблицы, которые включают в себя информацию о мониторинге и распространенности курения, создании среды, свободной от табачного дыма, лечении табачной зависимости, предупреждениях о вреде для здоровья на табачных упаковках, антитабачных кампаниях в средствах массовой информации, запретах на рекламу, стимулирование продажи и спонсорство табачных изделий, размерах налогообложения, а также о ценовой доступности табачных изделий, основанную на методологии, изложенной в Техническом примечании I. Во многих, но не во всех случаях, данные на уровне стран были представлены с приложением подтверждающих документов, таких как законы, нормативные положения, политические документы и т. д. ВОЗ проанализировала имеющиеся документы, и в настоящем приложении приводятся сводные показатели или индикаторы достижений стран по каждой из шести мер MPOWER. Подробная информация, включая детализированные сноски по каждому из показателей, содержится в Приложении II — в отношении лечения табачной зависимости, в Приложении VI — в отношении создания среды, свободной от табачного дыма, предупреждений о вреде для здоровья на табачных упаковках, антитабачных кампаний в средствах массовой информации, запретов на рекламу, стимулирование продажи и спонсорство табачных изделий, а также в Приложение IX — в отношении налогообложения и ценовой доступности табачных изделий. Важно отметить, что данные о законодательстве отражают статус законов, принятых до 31 декабря 2018 года, имеющих заявленную дату вступления в силу и не подвергающихся юридическому оспариванию, которое могло бы повлиять на эту дату. СВОДНЫЕ ДАННЫЕ О ПРИМЕНЕНИИ МЕР MPOWER ПО РЕГИОНАМ ПРИЛОЖЕНИЕ I: Сводные показатели, разработанные для Доклада ВОЗ о глобальной табачной эпидемии, 2019 г. являются такими же, как и те, что использовались для доклада за 2017 год. Методология, использованная для расчета каждого показателя, описана в Техническом примечании I. Тем не менее, этот аналитический обзор не является тщательным и полным правовым анализом законодательства каждой страны. За исключением среды, свободной от табачного дыма, и запретов на рекламу, стимулирование продажи и спонсорство табачных изделий, данные собирались только на национальном/федеральном уровне, и поэтому не полностью отражают меры, осуществляемые государствами-членами, в которых активная роль в борьбе против табака принадлежит субнациональным органам власти. Показатель распространенности ежедневного курения среди населения в возрасте 15 лет и старше в 2017 году является показателем, смоделированным ВОЗ на основании данных опросов о потреблении табака, опубликованных государствами-членами. Курение табака является одним из наиболее широко представленных показателей в проводимых странами опросах. Расчет оценок ВОЗ для возможности их сравнения между странами описан в Техническом примечании II. 144 145ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Африка Таблица 1.1 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Алжир 12% IIIII IIIII 34,2% ДА Ангола . . . . . . — 23,7% ДА p Бенин 5% IIIII IIIIIIII 4,9% НЕТ p q p Ботсвана 15% — . . . 49,9% ↔ p Буркина-Фасо 11% IIII IIIIII 41,6% ↔ Бурунди 7% — — 42,8% ↔ p p p Габон . . . IIIII IIIIIII 23,1% ↔ q Гамбия 10% — IIIIIII 46,3% ДА p p q Гана 3% — I IIIIIIII 31,3% НЕТ Гвинея . . . . . . . . . … … q Гвинея-Бисау . . . . . — — 6,8% ↔ q Демократическая Республика Конго . . . 8 — 8 38,7% НЕТ p p Замбия 10% III — 41,2% ↔ p Зимбабве 11% IIII — 35,9% ДА Кабо-Верде . . . IIIII IIIIIII 11,2% НЕТ Камерун 6% . . . 8 . . . 21,3% НЕТ p Кения 8% — IIIIIIIIII 52,3% НЕТ Коморские Острова 11% III IIIIII 37,3% ↔ p Конго 9% I IIIIIIII 37,1% ↔ p Кот-д’Ивуар 9% — — 33,3% НЕТ Лесото 21% . . . — 50,9% НЕТ Либерия 6% — — 34,8% ↔ p Маврикий 16% IIIIII IIIIIIIII 83,5% ДА p Мавритания . . . I 8 — 9,6% НЕТ p p Мадагаскар 16% IIII IIIIIIIII 80,4% ДА Малави 8% — — . . . . . . Мали 10% — IIIIIII 27,7% НЕТ Мозамбик 11% IIIIIIIIII 28,5% ДА p Намибия 13% IIIIII IIIIIIIIII 44,1% ↔ Нигер 5% III IIIIIIIII 31,3% ↔ Нигерия 3% — III 29,7% НЕТ p Объединенная Республика Танзания 8% — I . . . 32,1% ↔ q Руанда 9% — IIIIIIII 55,9% НЕТ q Сан-Томе и Принсипи 4% — I IIIIIIIII 40,4% НЕТ q Сейшельские Острова 16% IIIIIIIIII IIIIIIIIII 70,1% ↔ Сенегал 6% IIII I IIIIII 38,2% ДА Сьерра-Леоне 19% — — 18,6% ↔ Того 6% IIIIIIIIII I IIIIIIIIII 22,0% ↔ Уганда 5% III IIIIIII 39,9% ДА q Центральноафриканская Республика . . . — — 41,5% ↔ q Чад 7% III IIIIIII 34,1% ДА Экваториальная Гвинея . . . — — 25,3% ↔ Эритрея 5% — . . . 55,4% ↔ Эсватини 6% — IIIIIIIIII 52,7% НЕТ p Эфиопия 2% IIIII I IIIII 18,8% НЕТ Южная Африка 17% — . . . 54,6% ↔ p Южный Судан . . . — — . . . . . . РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I 146 147ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Америка Таблица 1.2 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. 1 Правительство Канады в течение отчетного периода не проводило общенациональных кампаний в СМИ. Однако кампании в средствах массовой информации были проведены в трех провинциях Канады. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Антигуа и Барбуда . . . I — 13,3% ↔ p p p Аргентина 16% IIIIIIII IIIIIIII 76,2% ДА Багамские Острова 8% — . . . . . . . . . Барбадос 5% IIIIIIIIII — 47,1% ДА p Белиз . . . — — 43,6% НЕТ Боливия (Многонациональное Государство) . . . II II 36,8% ↔ q Бразилия 11% IIIIIIIIII IIIIIIIII 83,0% ↔ p Венесуэла (Боливарианская Республика) . . . IIIIIIII IIIIIIIIII 73,0% . . . Гайана 11% IIIIIII 8 IIIIII 27,5% НЕТ p p p p Гаити 6% — — . . . . . . Гватемала . . . IIIII III 49,0% ↔ Гондурас . . . IIIIIIIIII IIIIII 33,4% ДА p Гренада . . . — — 44,0% ↔ Доминика . . . — — 23,6% ↔ q Доминиканская Республика 7% III — 51,1% НЕТ Канада1 10% IIIIIIIII IIIIIIIIII 64,3% ДА Колумбия 5% IIIIIII IIIIIII 78,4% ↔ p Коста-Рика 6% IIIII IIIIII 55,1% ДА Куба 19% IIII — 70,2% . . . Мексика 8% IIII I IIIII 67,0% ↔ Никарагуа . . . IIIII IIIIIII 40,2% ↔ Панама 3% IIIIIII IIIIIII 56,5% ↔ q Парагвай 9% IIIII IIIII 17,4% ↔ p Перу 7% IIIIII IIIIII 49,0% ДА Сальвадор 6% III IIIIIII 47,5% ↔ q Сент-Винсент и Гренадины . . . — — 16,9% ↔ Сент-Китс и Невис . . . — — 19,8% ↔ Сент-Люсия . . . . . . — 51,2% ↔ p Соединенные Штаты Америки 14% . . . . . . 43,0% ↔ Суринам . . . IIIII IIIIIIII 47,6% ДА q Тринидад и Тобаго . . . IIIIIIIII 8 IIIIIIII 25,7% ДА Уругвай 18% IIIIIIIII IIIIIIII 66,1% ↔ Чили 32% IIIIIIII IIIIIIIII 82,4% ДА Эквадор . . . IIIIIIII IIIIIII 70,0% ДА Ямайка 8% IIIIIIII IIIIIIII 43,6% ДА СОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности 148 149ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Юго-Восточная Азия Таблица 1.3 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. 1 Производство и продажа табачных изделий запрещены. Однако на всех табачных изделиях, ввозимых для личного потребления, должна быть указана страна происхождения, и должны быть нанесены предупреждения о вреде для здоровья. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Бангладеш 19% IIIIII IIIIII 71,0% ДА Бутан1 . . . IIIIIIIIII IIIIIIIIII — — Индия 10% IIIIIII I IIIIIII 54,0% ДА Индонезия 28% IIII 58,5% ↔ Корейская Народно- Демократическая Республика 13% IIIII — 0,0% . . . Мальдивские Острова . . . I IIII 68,7% ДА Мьянма 16% IIIII IIIIII 32,5% НЕТ Непал 15% IIIII IIIIIIII 30,0% ↔ Таиланд 17% IIIII IIIIII 78,6% ↔ p Тимор-Лешти 28% IIIIII IIIIIIII 21,8% ДА p p q Шри-Ланка 10% IIIIIIII IIIIIIIII 66,2% ДАСОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности 150 151ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Европа Таблица 1.4 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. 1 Заявленное соблюдение представляет собой рассчитанное среднее значение оценки двух экспертов из Федерации Боснии и Герцеговины и одного эксперта из Республики Сербской. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Австрия 23% IIIII IIIIIIIII 75,3% ДА Азербайджан 17% III I IIIIIIII 35,3% ↔ p p Албания 23% IIIII IIIIIIIII 67,2% ДА Андорра 28% IIIIIII I — 79,3% . . . p Армения 25% III IIII 38,1% НЕТ Беларусь 24% — IIIIII 50,9% ДА p Бельгия 21% IIIIIIII I IIIIIIIII 77,0% ДА Болгария 31% IIIIIII IIIIIIII 83,6% ↔ Босния и Герцеговина1 32% — IIIIIII 83,8% ДА Венгрия 26% IIIIIIIIII IIIIIIIIII 72,3% ДА Германия 22% — IIIIIII 68,3% ДА Греция 31% IIIIIIIII IIIIIII 81,2% ДА Грузия 25% — IIIIIII 71,2% ↔ p p p Дания 15% IIIIIIII IIIIIII 74,1% ↔ Израиль 21% . . . . . . 75,9% ДА q Ирландия 20% IIIIIIIIII IIIIIIIII 78,4% ↔ Исландия 11% IIIIIIIIII IIIIIIIIII 55,5% ↔ Испания 24% IIIIIIIII IIIIIIII 78,2% ДА p Италия 19% — I IIIIIIII 76,0% ДА Казахстан 17% IIIIIIII IIIIIIII 52,4% ДА p Кипр 30% . . . . . . 74,4% ДА p q Киргизия 21% II IIII 48,6% ↔ Латвия 31% IIIIIIIII IIIIIIIIII 80,0% ↔ Литва 22% IIIIIIII IIIIIIIIII 73,8% ↔ q Люксембург 17% IIIIIIIII I IIIIIIIIII 68,3% ДА p p Мальта 20% IIIIIIII IIIIIIIIII 77,6% НЕТ q Молдова 21% IIIIIII IIIIIII 58,0% ДА Монако . . . . . .I — . . . . . . Нидерланды 18% — IIIIIIIII 71,8% ДА Норвегия 13% IIIIIIIIII IIIIIIIIII 64,0% ДА Польша 23% … . . . 76,8% ДА Португалия 22% IIIIIII I IIIIII 71,7% ДА Российская Федерация 27% IIIIII IIIIIII 57,7% ДА Румыния 23% IIIIIIII IIIIIIIII 68,6% ↔ Сан-Марино . . . . . . I . . . . . . . . . q Северная Македония . . . IIIIIII IIIIIIIII 81,3% ↔ p Сербия 33% IIII IIIIII 77,3% ДА Словакия 24% IIIIIIII IIIIIIIIII 77,1% ДА p Словения 20% IIIIIIIII I IIIIIIIIII 79,2% ДА p p Соединенное Королевство Великобритании и Северной Ирландии 17% IIIIIIIIII . . . 79,4% ДА Таджикистан . . . IIII IIIIIII 42,3% ↔ p q p Туркменистан . . . IIIIIIII IIIIIIIIII 32,4% ДА Турция 25% IIIIIII IIIIII 81,4% ДА Узбекистан 10% IIII IIIIIIII 44,7% ↔ Украина 23% IIIIIII IIIIIIII 74,7% ДА q Финляндия 15% IIIIIIIIII IIIIIIIIII 87,4% ДА Франция 28% IIII I IIIIIIIII 82,4% ДА Хорватия 30% IIIIIIIII I IIIIIIIII 78,8% ДА p p Черногория . . . II IIIIII 81,4% ДА q p Чешская Республика 24% IIIIIIII IIIIIIIII 75,4% ДА p Швеция 10% — . . . 68,4% ДА p Швейцария 20% — IIIIII 60,3% ДА Эстония 24% IIIIII IIIIIIII 79,4% ДА q СОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности 152 153ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Восточное Средиземноморье Таблица 1.5 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. < Термин «Западный берег реки Иордан и сектор Газа» используется как синоним для обозначения оккупированной палестинской территории, включая восточный Иерусалим. 1 Заявленное соблюдение представляет собой рассчитанное среднее значение оценки экспертов из Западного берега реки Иордан и сектора Газа. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Афганистан . . . IIIIII 4,1% ДА q Бахрейн 15% — I IIIIIIIII 64,5% ДА p Джибути . . . . . . . . . . . . . . . q Египет 19% III IIIIIII 77,2% ДА p Западный берег реки Иордан и сектор Газа <1 . . . III IIIIIIII 83,5% . . . Йемен 13% IIIII IIIIII 50,6% ДА Иордания . . . III IIIII 80,5% ДА Ирак 16% III IIII 7,6% ↔ Иран (Исламская Республика) 9% IIIIIIII IIIIIIIIII 21,7% ДА q q Катар 11% — IIIIIIIIII 40,0% ДА p Кувейт 16% . . . . . . 21,2% ДА Ливан 24% III IIIIII 45,6% ↔ Ливия . . . III IIIIIIII 12,6% ДА Марокко 12% III IIIIII 71,2% НЕТ Объединенные Арабские Эмираты 12% IIIIIIIII I IIIIIIIII 73,5% ДА p Оман 6% — IIIIIIII 25,0% ДА q p Пакистан 13% III 8 IIIII 56,4% ↔ p Саудовская Аравия 11% IIIIIII I 8 IIIIIII 68,1% ДА p p p p Сирийская Арабская Республика . . . III IIIIIIIIII 41,8% . . . Сомали . . . — — 4,5% . . . Судан . . . — IIIIIIIII 69,8% ↔ p Тунис 20% — IIIIIIII 72,0% ↔ СОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности 154 155ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Западная часть Тихого океана Таблица 1.6 Сводные данные о применении мер MPOWER . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОКАЗАТЕЛЬ 2018 ГОДА И СОБЛЮДЕНИЕ ТРЕБОВАНИЙ ИЗМЕНЕНИЕ ПО СРАВНЕНИЮ С 2016 ГОДОМ СТРАНА РАСПРОСТРА- НЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ (2017 ГОД) M МОНИТО- РИНГ P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАМ- МЫ ПО ПРЕ- КРАЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R P ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА O ПРОГРАММЫ ПО ПРЕКРА- ЩЕНИЮ КУРЕНИЯ W ПРЕДУПРЕЖ- ДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ E ЗАПРЕТЫ НА РЕКЛАМУ R НАЛОГО- ОБЛОЖЕНИЕ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ ПРЕДУПРЕ- ДИТЕЛЬНЫЕ НАДПИСИ СМИ ЛИНИИ ОТОБРАЖАЮТ УРОВЕНЬ СОБЛЮДЕНИЯ НАЛОГООБЛО- ЖЕНИЕ СИГАРЕТЫ СТАЛИ МЕНЕЕ ДОСТУПНЫМИ В ЦЕНОВОМ ОТНО- ШЕНИИ ПОСЛЕ 2008 ГОДА ИЗМЕНЕНИЕ ЗНАЧЕНИЙ ПОКАЗАТЕЛЕЙ POWER, УВЕЛИЧЕНИЕ ИЛИ СНИЖЕНИЕ, ПО СРАВНЕНИЮ С 2016 ГОДОМ Австралия 13% . . . IIIIIIIIII 77,5% ДА p Бруней-Даруссалам 12% IIIIIII IIIIIIIIII — — q Вануату 13% — IIIIIIIII 58,6% НЕТ Вьетнам . . . III IIIIIIII 36,7% НЕТ p Камбоджа 16% III IIIIIIIII 25,1% НЕТ Кирибати 45% IIIII IIIIIIIII 41,7% НЕТ Китай 22% IIIII IIIIIII 55,7% НЕТ Лаосская Народно- Демократическая Республика 24% IIIII IIIIIIII 18,8% НЕТ Малайзия 18% — IIIII 58,6% ДА Маршалловы Острова . . . IIIIIII IIIIIIIIII 54,1% НЕТ Микронезия (Федеративные Штаты) . . . IIIIIIII — 48,6% ДА q Монголия 22% IIIII IIIIIIII 47,4% ↔ q Науру 38% . . . . . . 48,3% ДА q Ниуэ . . . — 8 8 — 8 87,7% . . . p p p Новая Зеландия 14% IIIIIIIIII IIIIIIIIII 82,2% ДА p Острова Кука 19% IIIIIIIIII IIIIIIIIII 70,3% ДА Палау 15% IIIIIII IIIIIIIII 73,0% ↔ Папуа-Новая Гвинея . . . . . . . . . 54,2% ↔ p p p Республика Корея 21% IIIIIIII . . . 73,8% ↔ Самоа 23% III IIIIIIIII 49,5% ДА q Сингапур 13% IIIIIIII I IIIIIIIIII 67,1% НЕТ Соломоновы Острова 30% IIIIIIIIII 34,1% ↔ Тонга 26% IIIIIII IIIIIIIIII 62,4% ДА Тувалу 30% IIIIIII IIIIIIII 29,5% ↔ q q Фиджи 17% IIIIIIII IIIIIIIII 42,1% ДА Филиппины 19% IIIII IIIII 71,3% ДА Япония 19% — 8 — 63,1% ДА p СОБЛЮДЕНИЕ ЗАКОНОДАТЕЛЬСТВА: СОБЛЮДЕНИЕ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ, А ТАКЖЕ ПРИВЕРЖЕННОСТЬ СОБЛЮДЕНИЮ ЗАКОНОВ ОБ ОБЕСПЕЧЕНИИ БЕЗДЫМНОЙ СРЕДЫ |||||||||| ||||||||| |||||||| Высокая степень соблюдения (от 8/10 до 10/10) ||||||| |||||| ||||| |||| ||| Умеренное соблюдение (от 3/10 до 7/10) || | Минимальное соблюдение (от 0/10 до 2/10) УСЛОВНЫЕ ОБОЗНАЧЕНИЯ I В стране есть один или несколько типов общественных мест, в которых разрешено организовывать помещения, специально предназначенные для курения. Отдельные, полностью изолированные помещения для курения разрешены, если они имеют отдельную вентиляцию с выходом во внешнюю среду, и/или в них поддерживается более низкий уровень давления по отношению к прилегающим зонам. Учитывая сложность соблюдения очень строгих требований, установленных для таких помещений, их организация кажется практически невозможной, но в настоящее время нет надежных фактических данных, позволяющих установить, были ли они сооружены. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. st Изменение значений показателей POWER, увеличение или снижение, в период с 2016 по 2018 год. Некоторые данные за 2016 год были пересмотрены в 2018 году. Принципы группировки 2018 года были применены к обоим годам. ОПРЕДЕЛЕНИЯ КАТЕГОРИЙ ПРЕДСТАВЛЕНЫ В ТЕХНИЧЕСКОМ ПРИМЕЧАНИИ I РАСПРОСТРАНЕННОСТЬ ЕЖЕДНЕВНОГО КУРЕНИЯ СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ*: ПОКАЗАТЕЛИ РАСПРОСТРАНЕННОСТИ ЕЖЕДНЕВНОГО КУРЕНИЯ ТАБАКА СРЕДИ ВЗРОСЛОГО НАСЕЛЕНИЯ, СТАНДАРТИЗИРОВАННЫЕ ПО ВОЗРАСТУ (ОБА ПОЛА В СОВОКУПНОСТИ), 2017 ГОД . . . Данные отсутствуют 30% или более От 20% до 29,9% От 15% до 19,9% Менее 15% * Данные должны использоваться исключительно для проведения сравнения между странами и не должны быть использованы для оценки абсолютного числа ежедневных курильщиков табака в стране. МОНИТОРИНГ: ДАННЫЕ О РАСПРОСТРАНЕННОСТИ КУРЕНИЯ Нет известных или недавних данных, либо данные не являются недавними и репрезентативными Недавние и репрезентативные данные по взрослым или по молодежи Недавние и репрезентативные данные как по взрослым, так и по молодежи Недавние, репрезентативные и периодические данные как по взрослым, так и по молодежи ПОЛИТИКА СОЗДАНИЯ СРЕДЫ, СВОБОДНОЙ ОТ ТАБАЧНОГО ДЫМА: ЗАПРЕТЫ НА КУРЕНИЕ Данные не представлены/не разбиты по категориям Полное отсутствие запрета, или до двух категорий общественных мест, полностью свободных от табачного дыма От трех до пяти категорий общественных мест, полностью свободных от табачного дыма От шести до семи категорий общественных мест, полностью свободных от табачного дыма Все общественные места полностью свободны от табачного дыма (или не менее 90% населения охвачено полным субнациональным законодательством об обеспечении бездымной среды) ПРОГРАММЫ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ: ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИ Данные не представлены Услуги для бросающих курить отсутствуют Никотинзаместительная терапия (НЗТ) и/или некоторые услуги для бросающих курить (и то и другое без компенсации затрат) НЗТ и/или некоторые услуги для бросающих курить (либо то, либо другое с компенсацией затрат) Общенациональная телефонная служба помощи для бросающих курить, а также НЗТ и некоторые услуги для бросающих курить (с компенсацией затрат) ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ: ПРЕДУПРЕДИТЕЛЬНЫЕ НАДПИСИ О ВРЕДЕ ДЛЯ ЗДОРОВЬЯ НА ПАЧКАХ СИГАРЕТ Данные не представлены Предупреждения отсутствуют или имеют небольшой размер Предупреждения имеют средний размер, но в них отсутствуют некоторые или многие требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют многие требуемые характеристики Предупреждения имеют средний размер и содержат все требуемые характеристики ИЛИ предупреждения имеют большой размер, но в них отсутствуют некоторые требуемые характеристики Предупреждения имеют большой размер и содержат все требуемые характеристики СМИ: АНТИТАБАЧНЫЕ РЕКЛАМНЫЕ КАМПАНИИ Данные не представлены В период с июля 2016 года по июнь 2018 года национальные кампании продолжительностью не менее трех недель не проводились Проведенная национальная кампания имела от одной до четырех требуемых характеристик Проведенная национальная кампания имела пять-шесть требуемых характеристик или семь характеристик, за исключением трансляции на телевидении и/или радио Проведенная национальная кампания имела не менее семи требуемых характеристик, включая трансляцию на телевидении и/или радио ЗАПРЕТЫ НА РЕКЛАМУ: ЗАПРЕТЫ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Данные не представлены Полное отсутствие запрета или запрет, не распространяющийся на национальное телевидение, радио и печатные СМИ Запрет касается только национального телевидения, радио и печатных СМИ Запрет распространяется на национальное телевидение, радио и печатные СМИ, а также на определенные, но не на все виды прямой и/ или косвенной рекламы Запрет на все виды прямой и косвенной рекламы (или не менее 90% населения, охваченного полными субнациональными запретами) НАЛОГООБЛОЖЕНИЕ: ДОЛЯ СОВОКУПНЫХ НАЛОГОВ В РОЗНИЧНОЙ ЦЕНЕ САМОЙ ШИРОКО ПРОДАВАЕМОЙ МАРКИ СИГАРЕТ Данные не представлены Налог составляет <25% от розничной цены Налог составляет ≥25% и <50% от розничной цены Налог составляет ≥50% и <75% от розничной цены Налог составляет ≥75% от розничной цены ЦЕНОВАЯ ДОСТУПНОСТЬ СИГАРЕТ ДА Сигареты менее доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем увеличился НЕТ Сигареты более доступны в ценовом отношении – ВВП на душу населения, необходимый для покупки 2000 сигарет самой продаваемой марки, в период с 2008 по 2018 год в среднем снизился ↔ С 2008 года не наблюдается никаких изменений в ценовой доступности сигарет . . . Недостаточно данных для анализа тенденций изменения ценовой доступности 156 157ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В Приложении II представлена подробная информация о доступности лечения табачной зависимости в государствах- членах ВОЗ по каждому региону ВОЗ. Данные, содержащиеся в приложении, были предоставлены государствами-членами и проанализированы ВОЗ. В настоящем приложении приводятся следующие данные: Предоставляемая поддержка в лечении табачной зависимости: l Наличие национальной бесплатной телефонной линии для бросающих курить l Оказание поддержки в отказе от употребления табака в медицинских и других учреждениях, а также то, предоставляется ли она в качестве услуги, затраты на которую подлежат компенсации l Доступность никотинзаместительной терапии и компенсация затрат на нее ЛЕЧЕНИЕ ТАБАЧНОЙ ЗАВИСИМОСТИПРИЛОЖЕНИЕ II: Меры политики и руководства: Наличие национальных мер политики и клинических руководств по прекращению употребления табака Интеграция услуг по прекращению курения в другие подходы к борьбе против табака: использование информации о телефонных линиях по прекращению курения при проведении кампаний в средствах массовой информации и включение телефонных номеров этих линий в предупреждения о вреде употребления табака для здоровья Структурный потенциал: систематическое осуществление программ подготовки в отношении прекращения употребления табака для работников служб первичной медико-санитарной помощи и постоянная регистрация факта употребления табака в медицинских записях 158 159ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Африка СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ Алжир Нет Аптека Нет Да Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Нет — Нет — Ангола Нет Нет в наличии — — Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Бенин Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Ботсвана Нет Аптека с Rx Нет . . . Да, в некоторых Полная Нет — Нет — Да, в некоторых Нет Да, в некоторых Нет Буркина-Фасо Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых . . . Нет — Бурунди Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Габон Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Нет — Гамбия Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — . . . . . . Гана Нет Нет в наличии — Нет Нет — Да, в некоторых Частичная Да, в некоторых Нет Нет — Нет — Гвинея-Бисау Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Гвинея Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Демократическая Республика Конго Нет Аптека Нет Нет Нет — Нет — Да, в некоторых Нет Нет — Нет — Замбия Нет Аптека с Rx Частичная Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Нет Нет — Зимбабве Нет Аптека с Rx Нет Нет Нет — Нет — Да, в некоторых Частичная Нет — Да, в некоторых . . . Кабо-Верде Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых . . . Да, в некоторых Частичная Камерун Да . . . Нет Нет Нет — Нет — Да, в некоторых Частичная Нет — Да, в некоторых Частичная Кения Да Аптека Нет Нет Нет — Да, в некоторых Частичная Нет — Да, в некоторых . . . Да, в некоторых Частичная Коморские Острова Нет Нет в наличии — Нет Нет — Нет — Да, в некоторых Нет . . . . . . Да, в некоторых Нет Конго Нет Аптека Частичная Нет Нет — Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Кот-д’Ивуар Да Аптека Частичная Нет Да, в некоторых Нет Да, в некоторых Нет Нет — Да, в некоторых Нет Да, в некоторых Нет Лесото Нет Аптека с Rx Нет Нет Нет — Нет — Да, в большинстве Полная Да, в некоторых Нет Да, в большинстве Частичная Либерия Нет Нет в наличии — Нет Да, в некоторых Нет Нет — Да, в некоторых Нет Нет — Нет — Маврикий Нет Аптека Полная Нет Нет — Нет — Да, в большинстве Нет Нет — Да, в некоторых Полная Мавритания Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Мадагаскар Нет Аптека Нет Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Малави Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Мали Нет Нет в наличии — Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Нет — Мозамбик Нет Нет в наличии — . . . Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых . . . Нет — Намибия Нет Аптека Нет . . . Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Нет Нет — Да, в некоторых Частичная Нигер Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Нет — Нигерия Нет Аптека Частичная Нет Нет — Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Объединенная Республика Танзания Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых Нет Нет — Руанда Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Сан-Томе и Принсипи Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Сейшельские Острова Нет Аптека Полная Нет Нет — Нет — Нет — Нет — Да, в некоторых Полная Сенегал Да Аптека с Rx Частичная Нет Да, в некоторых Частичная Нет — Да, в некоторых Частичная Да, в некоторых Нет Нет — Сьерра-Леоне Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Того Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Уганда Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Да, в большинстве Нет Центральноафриканская Республика Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Чад Нет . . . Нет Нет Нет — Нет — Нет — Да, в некоторых Нет Нет — Экваториальная Гвинея Нет Нет в наличии — . . . Нет — Нет — Нет — Нет — Нет — Эритрея Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Эсватини Нет Аптека с Rx Полная Нет Нет — Нет — Нет — Нет — Нет — Эфиопия Нет . . . Частичная Да Нет — Нет — Нет — Нет — Да, в некоторых Частичная Южная Африка Нет Аптека Нет Да Нет — Нет — Нет — Да, в большинстве Нет Да, в некоторых Полная Южный Судан . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Таблица 2.1.1 Оказание поддержки в лечении табачной зависимости в странах Африки § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 160 161ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Америка СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ Антигуа и Барбуда Нет Аптека Нет Нет Нет — Нет — Да, в некоторых Нет Нет — Нет — Аргентина Да Аптека Нет Нет Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Багамские Острова Нет Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Да, в некоторых Полная Барбадос Нет Аптека Нет Да Нет — Нет — Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Полная Белиз Нет Нет в наличии — Нет Да, в некоторых Частичная Да, в некоторых Нет Нет — Нет — Да, в некоторых Частичная Боливия (Многонациональное Государство) Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Бразилия Да Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Нет Нет — Венесуэла (Боливарианская Республика) Нет Аптека Полная Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Гаити Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Гайана Нет . . . Нет Да Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Да, в некоторых Полная Гватемала Нет Аптека Нет Нет Нет — Да, в некоторых Частичная Да, в некоторых Нет Нет — Да, в некоторых Нет Гондурас Да Нет в наличии — Нет Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Гренада Нет Нет в наличии — Нет Да, в некоторых Частичная Нет — Да, в некоторых Нет Нет — Нет — Доминика Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Доминиканская Республика Нет Аптека Нет Нет Нет — Нет — Да, в большинстве Нет Нет — Да, в некоторых Нет Канада Да Аптека Частичная Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Нет Да, в некоторых Частичная Колумбия Нет Аптека Частичная Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Нет Коста-Рика Нет Аптека Полная Нет Да, в некоторых Полная Да, в большинстве Полная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Частичная Куба Да Нет в наличии — Нет Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Полная Мексика Да Аптека Частичная Да Да, в большинстве Полная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Никарагуа Нет Аптека Нет Да Нет — Нет — Нет — Нет — Нет — Панама Нет Аптека Полная Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Парагвай Нет Нет в наличии — Да Нет — Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Перу Да Аптека с Rx Нет Нет Нет — Да, в некоторых Полная Нет — Нет — Нет — Сальвадор Да Аптека с Rx Полная Нет Нет — Нет — Нет — Нет — Да, в некоторых Полная Сент-Винсент и Гренадины Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых . . . Нет — Сент-Китс и Невис Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Нет — Сент-Люсия Нет . . . Нет Нет Нет — Нет — Нет — Нет — Да, в некоторых Частичная Соединенные Штаты Америки Да Универсальный магазин Частичная Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Суринам Нет Аптека Нет Да Да, в большинстве Полная Нет — Нет — Да, в некоторых Нет Да, в некоторых Нет Тринидад и Тобаго Нет Аптека Полная Да Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Нет Нет — Нет — Уругвай Нет Аптека Полная Да Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Полная Да, в некоторых Нет Да, в некоторых Полная Чили Да Аптека Нет Нет Нет — Нет — Нет — Нет — Да, в некоторых Нет Эквадор Да Нет в наличии — Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Ямайка Да Аптека с Rx Полная Да Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Таблица 2.1.2 Оказание поддержки в лечении табачной зависимости в странах Америки § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 162 163ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕНСА-ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ Бангладеш Нет Нет в наличии — Нет Да, в некоторых Нет Да, в некоторых Нет Нет — Да, в некоторых Нет Нет — Бутан Да Нет в наличии — . . . Да, в большинстве Частичная Да, в некоторых Частичная Нет — Нет — Да, в некоторых Нет Индия Да Универсальный магазин Полная Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых . . . Да, в некоторых . . . Да, в некоторых Полная Индонезия Да Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Нет Да, в некоторых Нет Нет — Корейская Народно-Демократическая Республика Нет . . . Частичная . . . Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Частичная Да, в большинстве Полная Мальдивские Острова Нет Аптека с Rx Полная Да Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Частичная Нет — Да, в некоторых Полная Мьянма Нет Нет в наличии — Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Нет — Непал Нет Нет в наличии — Нет Да, в некоторых Нет Да, в некоторых Полная Нет — Нет — Нет — Таиланд Да Аптека Нет Нет Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Полная Да, в большинстве Частичная Да, в некоторых Полная Тимор-Лешти Да Нет в наличии — Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Полная Нет — Нет — Шри-Ланка Да Нет в наличии — Нет Нет — Нет — Да, в большинстве Полная Да, в некоторых Частичная Да, в некоторых Частичная Таблица 2.1.3 Оказание поддержки в лечении табачной зависимости в странах Юго- Восточной Азии § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. Юго-Восточная Азия ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 164 165ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Европа СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕН- САЦИЯ ЗАТРАТ Австрия Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых . . . Да, в некоторых Частичная Азербайджан Да Нет в наличии — Нет Нет — Нет — Нет — Нет — Да, в некоторых Нет Албания Нет Нет в наличии — Нет Да, в некоторых Полная Нет — Нет — Нет — Нет — Андорра Нет Аптека Нет Нет Нет — Да, в некоторых Частичная Да, в некоторых Частичная . . . . . . . . . . . . Армения Нет Аптека Нет Нет Да, в некоторых Полная Нет — Нет — . . . . . . Нет — Беларусь Да Аптека Нет Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Частичная Нет — Нет — Бельгия Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Болгария Да Аптека Нет Да Да, в некоторых Частичная Нет — Да, в некоторых Нет Да, в некоторых Частичная Да, в некоторых Полная Босния и Герцеговина Нет Аптека Нет Нет Да, в большинстве Полная Нет — Нет — Нет — Да, в некоторых Нет Венгрия Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых . . . Да, в некоторых Частичная Германия Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Греция Нет Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Грузия Да Аптека Нет — Да, в некоторых Частичная Нет — Нет — Нет — Нет — Дания Да Аптека Частичная . . . Да, в некоторых Нет Нет — Нет — Да, в большинстве Полная Да, в некоторых Полная Израиль Нет Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Да, в некоторых Полная Ирландия Да Универсальный магазин Частичная Да Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Частичная Исландия Да Универсальный магазин Нет Да Нет — Нет — Нет — Да, в некоторых . . . Нет — Испания Нет Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Частичная Италия Да Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Казахстан Нет Аптека Нет Нет Да, в некоторых Полная Нет — Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Кипр Нет Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Да, в некоторых Полная Киргизия Да Нет в наличии — Нет Да, в большинстве Частичная Нет — Да, в большинстве Частичная Да, в некоторых Нет Да, в некоторых Частичная Латвия Да Аптека Нет Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Литва Нет Аптека Нет Да Да, в некоторых Полная Нет — Нет — . . . . . . Да, в некоторых Нет Люксембург Да Аптека Частичная Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная . . . . . . Да, в некоторых Частичная Мальта Да Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Полная Нет — Молдова Да Нет в наличии — Нет Да, в некоторых Полная Нет — Нет — . . . . . . Да, в некоторых Частичная Монако Нет Аптека Полная . . . . . . . . . Да, в большинстве Частичная Да, в большинстве Частичная . . . . . . . . . . . . Нидерланды Да Аптека Полная Да Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Частичная Да, в некоторых Частичная Норвегия Нет Универсальный магазин Нет Нет Да, в некоторых Частичная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Нет Да, в некоторых Частичная Польша Да Аптека Нет Нет Да, в некоторых Частичная Нет — Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Португалия Нет Нет в наличии — Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Да, в некоторых Частичная Российская Федерация Да Нет в наличии — Да Да, в некоторых Полная Нет — Нет — Нет — Нет — Румыния Да Аптека Нет Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Сан-Марино Нет Нет в наличии — Нет Нет — Нет — Нет — . . . . . . Нет — Северная Македония Нет Аптека Нет Нет Нет — Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Полная Сербия Нет Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Словакия Да Аптека Частичная Нет Нет — Нет — Да, в некоторых Частичная Нет — Да, в некоторых Полная Словения Да Аптека Нет Да Да, в некоторых Полная Нет — Нет — Да, в некоторых Частичная Да, в некоторых Полная Соединенное Королевство Велико- британии и Северной Ирландии Нет Универсальный магазин Частичная . . . Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в большинстве Полная Да, в некоторых Полная Таджикистан Нет Нет в наличии — Да Нет — Нет — Нет — . . . . . . Нет — Туркменистан Да Аптека Нет Да Да, в большинстве Полная Да, в некоторых Полная Да, в большинстве Полная Нет — Да, в некоторых Полная Турция Да Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Частичная Да, в некоторых Частичная Узбекистан Нет Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Нет — Нет — Нет — Украина Да Аптека Нет Нет Да, в некоторых Нет Нет — Нет — Нет — Нет — Финляндия Да Универсальный магазин Нет Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Частичная Да, в некоторых . . . Да, в некоторых Частичная Франция Нет Аптека Частичная Нет Да, в некоторых Частичная Да, в большинстве Частичная Да, в некоторых Частичная . . . . . . Да, в некоторых Частичная Хорватия Да Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Нет Да, в некоторых Частичная Черногория Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Чешская Республика Да Аптека Частичная — Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Швейцария Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Нет Да, в большинстве Частичная Да, в некоторых Нет . . . . . . Швеция Да Универсальный магазин Частичная Да Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Эстония Да Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Да, в некоторых Полная Таблица 2.1.4 Оказание поддержки в лечении табачной зависимости в странах Европы § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 166 167ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Восточное Средиземноморье СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕНСА-ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ Афганистан Нет Аптека Нет Нет Да, в некоторых Нет Нет — Нет — Нет — Нет — Бахрейн Нет Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Нет — Джибути Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Египет Да Нет в наличии — Нет Нет — Нет — Нет — Нет — Да, в некоторых Частичная Западный берег реки Иордан и сектор Газа < Нет Аптека Нет Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Иордания Нет Аптека Полная Нет Да, в некоторых Полная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Ирак Нет Аптека Частичная Да Да, в некоторых Частичная Нет — Нет — Нет — Нет — Иран (Исламская Республика) Да Аптека Нет Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Нет Да, в некоторых Нет Йемен Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых Нет Нет — Катар Нет Аптека с Rx Полная Да Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых . . . Нет — Да, в некоторых Частичная Кувейт Да Аптека Полная Да Да, в некоторых Полная Нет — Нет — Да, в большинстве Частичная Да, в некоторых Полная Ливан Нет Нет в наличии — Нет Да, в некоторых Частичная Нет — Нет — Да, в некоторых Частичная Нет — Ливия Нет Нет в наличии — Нет Да, в некоторых Частичная Нет — Нет — Нет — Да, в некоторых Частичная Марокко Нет Аптека с Rx Нет Нет Да, в большинстве Нет Да, в некоторых Нет Да, в некоторых Нет Нет — Нет — Объединенные Арабские Эмираты Да Аптека Частичная . . . Да, в некоторых Частичная Нет — Да, в некоторых . . . Да, в некоторых Частичная Да, в некоторых Полная Оман Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Нет — Пакистан Нет . . . Нет Нет Нет — Нет — Нет — Да, в некоторых Частичная Да, в некоторых Частичная Саудовская Аравия Да Аптека Полная Да Да, в большинстве Полная Да, в некоторых Полная Нет — Да, в большинстве Нет Да, в некоторых Полная Сирийская Арабская Республика Нет Нет в наличии — Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в большинстве Частичная Нет — Нет — Сомали Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Судан Нет Нет в наличии — Нет Да, в некоторых Нет Нет — Нет — Нет — Нет — Тунис Нет Аптека с Rx Полная Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Таблица 2.1.5 Оказание поддержки в лечении табачной зависимости в странах Восточного Средиземноморья § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. < Термин «Западный берег реки Иордан и сектор Газа» используется как синоним для обозначения оккупированной палестинской территории, включая восточный Иерусалим. ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 168 169ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Западная часть Тихого океана СТРАНА НАЦИО- НАЛЬНАЯ БЕСПЛАТНАЯ ТЕЛЕФОН- НАЯ СЛУЖ- БА ПОМОЩИ ДЛЯ БРО- САЮЩИХ КУРИТЬ НИКОТИНЗАМЕСТИТЕЛЬНАЯ ТЕРАПИЯ ГДЕ ИМЕЕТСЯ В НАЛИЧИИ§ КОМПЕНСАЦИЯ ЗАТРАТ ВХОДИТ В ПЕРЕЧЕНЬ ОСНОВНЫХ ЛЕКАРСТВЕННЫХ СРЕДСТВ УЧРЕЖДЕНИЯ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ БОЛЬНИЦЫ КАБИНЕТЫ ВРАЧЕЙ МЕСТНЫЕ СООБЩЕСТВА ДРУГИЕ УЧРЕЖДЕНИЯ НАЛИЧИЕ* КОМПЕНСА-ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ НАЛИЧИЕ* КОМПЕНСА- ЦИЯ ЗАТРАТ Австралия Да Универсальный магазин Частичная Да Да, в большинстве Частичная Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых . . . Да, в некоторых Частичная Бруней-Даруссалам Нет Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Нет — Да, в некоторых Полная Нет — Вануату Нет Аптека Нет Да Нет — Нет — Нет — Нет — Нет — Вьетнам Да Аптека Нет Нет Да, в некоторых Частичная Да, в некоторых Частичная Нет — Нет — Нет — Камбоджа Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых Нет Нет — Кирибати Нет Нет в наличии — Нет Да, в большинстве Полная Да, в некоторых Полная Нет — Нет — Нет — Китай Нет Нет в наличии — Нет Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Да, в некоторых Частичная Лаосская Народно-Демократическая Республика Нет Нет в наличии — Нет Нет — Нет — Нет — Нет — Нет — Малайзия Нет Аптека Полная Да Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Нет Нет — Маршалловы Острова Нет Аптека Частичная Да Нет — Нет — Нет — Нет — Нет — Микронезия (Федеративные Штаты) Да . . . Нет Нет Да, в большинстве Полная Нет — Да, в некоторых Полная Да, в некоторых Нет Да, в некоторых Нет Монголия Нет Аптека Частичная Да Да, в некоторых Частичная Да, в некоторых Нет Нет — Нет — Нет — Науру Нет Нет в наличии — Нет Нет — Да, в некоторых Нет Нет — Нет — Нет — Ниуэ Нет Аптека Полная Нет Нет — Нет — Нет — Нет — Нет — Новая Зеландия Да Универсальный магазин Полная Да Да, в большинстве Частичная Да, в большинстве Полная Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Полная Острова Кука Нет Аптека Полная Нет Да, в большинстве Полная Да, в большинстве Полная Нет — Да, в большинстве Частичная Нет — Палау Нет Универсальный магазин Частичная Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Нет — Папуа-Новая Гвинея Нет Аптека Нет Нет Нет — Нет — Нет — Нет — Нет — Республика Корея Да Аптека Частичная Нет Да, в некоторых Полная Да, в некоторых Полная Да, в некоторых Полная . . . . . . Да, в большинстве Полная Самоа Нет Аптека Нет Нет Нет — Нет — Нет — Да, в некоторых Полная Нет — Сингапур Да Аптека Частичная Нет Да, в большинстве Частичная Да, в большинстве Частичная Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Частичная Соломоновы Острова Нет . . . Нет Нет Да, в некоторых Полная Нет — Нет — Нет — Нет — Тонга Да Аптека Нет Нет Да, в большинстве Полная Да, в некоторых Полная Нет — Нет — Нет — Тувалу Нет Нет в наличии — Нет Нет — Нет — Нет — Да, в некоторых Нет Нет — Фиджи Нет Аптека Нет Нет Да, в некоторых Полная Да, в некоторых Полная Нет — Нет — Нет — Филиппины Нет Аптека с Rx Нет Да Да, в некоторых Частичная Да, в некоторых Частичная Да, в некоторых Нет Нет — Да, в некоторых Полная Япония Нет Аптека Частичная Да Да, в некоторых Частичная Да, в некоторых Частичная Нет — Да, в некоторых Частичная Нет — Таблица 2.1.6 Оказание поддержки в лечении табачной зависимости в странах Западной части Тихого океана § «Аптека с Rx» означает, что для получения лекарства в этой аптеке требуется рецепт. * «В большинстве» означает более чем в половине. «В некоторых» означает менее чем в половине. «Нет» означает вообще ни в одном. . . . Данные не представлены/ отсутствуют. — Данные не требуются/ неприменимы. ПОДДЕРЖКА В ОТКАЗЕ ОТ КУРЕНИЯ 170 171ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Африка Таблица 2.2.1 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Африки СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Алжир Да Да Да Нет Нет Нет Ангола . . . . . . . . . . . . . . . . . . Бенин Нет Да Да Нет Нет Нет Ботсвана Нет Нет Да Нет Нет Нет Буркина-Фасо Нет Нет Нет Нет Нет Нет Бурунди Нет Нет Да Нет Нет Нет Габон Нет Нет Нет Нет Нет Нет Гамбия Нет Да Да Нет Нет Нет Гана Да Да Да Нет Нет Нет Гвинея-Бисау Нет Нет Нет Нет Нет Нет Гвинея Нет Да Да Нет Нет Нет Демократическая Республика Конго Нет Нет Нет Нет Нет Нет Замбия Нет Нет Нет Нет Нет Нет Зимбабве Нет Нет Да Нет Нет Нет Кабо-Верде Нет Нет Да Нет Нет Нет Камерун Нет Нет Нет Нет Нет Нет Кения Да Да Нет Да Нет Нет Коморские Острова Нет Нет Нет Нет Нет Нет Конго Нет Нет Да Нет Нет Нет Кот-д’Ивуар Да Да Нет Нет Нет Нет Лесото Нет Нет Нет Нет Нет Нет Либерия Нет Нет Нет Нет Нет Нет Маврикий Да Нет Да Нет Нет Нет Мавритания Нет Нет Нет Нет Нет Нет Мадагаскар Нет Да Да Нет Нет Нет Малави Нет Нет Нет Нет Нет Нет Мали Нет Нет Да Нет Нет Нет Мозамбик Нет Нет Нет Нет Нет Нет Намибия Да Нет Да Нет Нет Нет Нигер Нет Нет Нет Нет Нет Нет Нигерия Нет Нет Нет Да Нет Нет Объединенная Республика Танзания Нет Нет Нет Нет Нет Нет Руанда Нет Нет Да Нет Нет Нет Сан-Томе и Принсипи Нет Нет Нет Нет Нет Нет Сейшельские Острова Нет Нет Да Да Нет Нет Сенегал Нет Нет Да Нет Нет Нет Сьерра-Леоне Нет Нет Нет Нет Нет Нет Того Да Да Да Нет Нет Нет Уганда Нет Да Да Нет Нет Нет Центральноафриканская Республика Нет Нет Нет Нет Нет Да Чад Нет Нет Нет Нет Нет Нет Экваториальная Гвинея . . . . . . . . . . . . . . . . . . Эритрея Нет Нет Да Нет Нет Нет Эсватини Нет Нет Нет Нет Нет Нет Эфиопия Да Да Да Нет Нет Нет Южная Африка . . . . . . . . . . . . . . . . . . Южный Судан Нет Нет Нет Нет Нет Нет . . . Данные не представлены/ отсутствуют. 172 173ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Америка Таблица 2.2.2 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Америки . . . Данные не представлены/ отсутствуют. СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Антигуа и Барбуда Нет Нет Да Нет Нет Нет Аргентина Нет Да Да Нет Да Да Багамские Острова . . . . . . . . . . . . . . . . . . Барбадос Нет Нет Да Нет Нет Нет Белиз Нет Нет Да Нет Нет Нет Боливия (Многонациональное Государство) Нет Нет Нет Нет Нет Нет Бразилия Да Да Да Нет Да Нет Венесуэла (Боливарианская Республика) Да Нет Нет Нет Нет Нет Гаити Нет Нет Нет Нет Нет Нет Гайана Нет Да Да Нет Нет Нет Гватемала Нет Да Да Нет Нет Нет Гондурас Да Да Да Да Нет Нет Гренада Нет Нет Да Нет Нет Нет Доминика Нет Нет Да Нет Нет Нет Доминиканская Республика Нет Нет Да Нет Нет Нет Канада Нет Да Да Нет Да Да Колумбия Да Нет Да Нет Нет Да Коста-Рика Нет Да Да Да Нет Да Куба Да Да Да Да Нет Да Мексика Да Да Да Да Да Нет Никарагуа Нет Нет Да Нет Нет Нет Панама Да Да Да Да Нет Нет Парагвай Нет Нет Да Нет Нет Нет Перу Нет Нет Да Нет Нет Нет Сальвадор Нет Нет Да Нет Нет Нет Сент-Винсент и Гренадины Нет Нет Нет Нет Нет Нет Сент-Китс и Невис Нет Нет Да Нет Нет Нет Сент-Люсия Нет Нет Да Нет Нет Нет Соединенные Штаты Америки Да Да Да Нет Да Да Суринам Нет Нет Да Нет Нет Нет Тринидад и Тобаго Да Нет Да Нет Нет Нет Уругвай Да Да Да Да Нет Да Чили Нет Да Да Нет Нет Да Эквадор Нет Да Да Нет Да Да Ямайка Нет Да Да Нет Нет Нет 174 175ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 2.2.3 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Юго- Восточной Азии Юго-Восточная Азия СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Бангладеш Нет Нет Да Нет Нет Нет Бутан Нет Да Да Да Нет Нет Индия Да Да Да Нет Да Да Индонезия Да Да Да Нет Да Да Корейская Народно-Демократическая Республика Нет Да Да Нет Нет Нет Мальдивские Острова Нет Да Нет Нет Нет Нет Мьянма Да Нет Нет Да Нет Да Непал Нет Нет Нет Нет Нет Нет Таиланд Да Да Да Да Да Да Тимор-Лешти Нет Нет Нет Нет Нет Нет Шри-Ланка Да Нет Да Нет Да Нет 176 177ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД . . . Данные не представлены/ отсутствуют. Европа Таблица 2.2.4 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Европыа СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Австрия Нет Нет Да Нет Да Да Азербайджан Нет Да Да Да Нет Нет Албания Нет Нет Да Нет Нет Нет Андорра Нет Нет Да Нет Нет Нет Армения Да Да Да Нет Нет Нет Беларусь Нет Да Да Нет Да Нет Бельгия Да Да Да Нет Нет Да Болгария Да Да Да Да Нет Да Босния и Герцеговина . . . . . . . . . . . . . . . . . . Венгрия Нет Да Нет Да Да Да Германия Нет Да Да Нет Да Да Греция Да Нет Да Нет Нет Да Грузия Да Да Да Да Да Да Дания Нет Да Да Нет Да Нет Израиль . . . . . . . . . . . . . . . . . . Ирландия Да Нет Да Нет Да Да Исландия Нет Нет Нет Нет Да Да Испания Да Да Да Нет Нет Да Италия Да Да Да Нет Да Нет Казахстан Да Да Да Да Нет Нет Кипр Да Да Да Нет Нет Да Киргизия Нет Да Да Нет Да Нет Латвия Да Нет Да Да Да Нет Литва Нет Нет Да Нет Нет Да Люксембург Да Да Да Нет Да Нет Мальта Нет Нет Нет Нет Да Да Молдова Да Нет Да Да Да Нет Монако Нет Нет Нет Нет Нет Нет Нидерланды Да Да Да Нет Да Да Норвегия Да Да Да Нет Нет Нет Польша Да Нет Да Нет Да Да Португалия Да Да Да Нет Нет Нет Российская Федерация Нет Да Да Да Да Да Румыния Нет Нет Да Нет Да Да Сан-Марино Да Нет Да Нет Да Нет Северная Македония Нет Нет Да Да Нет Нет Сербия Нет Нет Да Нет Нет Нет Словакия Да Да Нет Нет Да Нет Словения Да Нет Нет Да Да Да Соединенное Королевство Великобритании и Северной Ирландии Да Да Да Да Нет Да Таджикистан Нет Да Да Да Нет Нет Туркменистан Нет Да Да Нет Да Нет Турция Да Да Да Нет Да Нет Узбекистан Нет Нет Да Нет Нет Да Украина Нет Да Да Нет Нет Нет Финляндия Нет Да Да Нет Нет Нет Франция Да Да Да Да Нет Да Хорватия Нет Да Да Да Да Нет Черногория Нет Нет Да Нет Нет Нет Чешская Республика Нет Да Да Да Да Нет Швейцария Да Да Да Нет Да Да Швеция Да Да Да Нет Да Да Эстония Да Да Да Да Нет Нет 178 179ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД . . . Данные не представлены/ отсутствуют. < Термин «Западный берег реки Иордан и сектор Газа» используется как синоним для обозначения оккупированной палестинской территории, включая восточный Иерусалим. Восточное Средиземноморье Таблица 2.2.5 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Восточного Средиземноморья СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Афганистан Да Нет Нет Нет Нет Нет Бахрейн Да Да Да Нет Нет Да Джибути . . . . . . . . . . . . . . . . . . Египет Нет Да Да Нет Да Нет Западный берег реки Иордан и сектор Газа < Да Нет Да Нет Нет Нет Иордания Да Нет Нет Нет Нет Нет Ирак Да Да Да Да Нет Нет Иран (Исламская Республика) Да Да Нет Да Нет Да Йемен Да Нет Нет Нет Нет Нет Катар Нет Да Да Нет Нет Да Кувейт Да Да Да Да Нет Нет Ливан Да Нет Да Нет Нет Нет Ливия Нет Нет Нет Нет Нет Нет Марокко Да Да Да Нет Нет Нет Объединенные Арабские Эмираты Да Нет Да Да Да Да Оман Да Нет Да Нет Нет Нет Пакистан Нет Нет Нет Нет Нет Нет Саудовская Аравия Да Да Да Да Нет Нет Сирийская Арабская Республика Нет Нет Нет Нет Нет Да Сомали . . . . . . . . . . . . . . . . . . Судан Нет Нет Нет Нет Нет Нет Тунис Да Да Нет Нет Нет Да 180 181ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 2.2.6 Оказание поддержки в прекращении употребления табака, дополнительная информация по странам Западной части Тихого океана Западная часть Тихого океана СТРАНА В СТРАНЕ ДЕЙСТВУЕТ НАЦИОНАЛЬНАЯ СТРАТЕГИЯ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА В СТРАНЕ ЕСТЬ НАЦИОНАЛЬНЫЕ КЛИНИЧЕСКИЕ РЕКОМЕНДАЦИИ ПО ПРЕКРАЩЕНИЮ УПОТРЕБЛЕНИЯ ТАБАКА ИНФОРМАЦИЯ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА СОДЕРЖИТСЯ КАК МИНИМУМ В ОДНОМ НАЦИОНАЛЬНОМ РУКОВОДСТВЕ ПО ЛЕЧЕНИЮ КОНКРЕТНЫХ ЗАБОЛЕВАНИЙ ФАКТ УПОТРЕБЛЕНИЯ ТАБАКА ПАЦИЕНТАМИ В ОБЯЗАТЕЛЬНОМ ПОРЯДКЕ РЕГИСТРИРУЕТСЯ В ИХ МЕДИЦИНСКИХ КАРТАХ ИНФОРМАЦИЯ О ТЕЛЕФОННЫХ ЛИНИЯХ ПО ПРЕКРАЩЕНИЮ КУРЕНИЯ ВКЛЮЧЕНА В ПРЕДУПРЕЖДЕНИЯ О ВРЕДЕ ТАБАКА ДЛЯ ЗДОРОВЬЯ ИЛИ ИСПОЛЬЗУЕТСЯ ПРИ ПРОВЕДЕНИИ КАМПАНИЙ В СМИ ВОПРОСЫ ПОДГОТОВКИ В ОТНОШЕНИИ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ВКЛЮЧЕНЫ В УЧЕБНЫЕ ПРОГРАММЫ МЕДИЦИНСКОГО ОБРАЗОВАНИЯ, ИЛИ РАБОТНИКИ СЛУЖБ ПЕРВИЧНОЙ МЕДИКО-САНИТАРНОЙ ПОМОЩИ РЕГУЛЯРНО ПРОХОДЯТ ПОДГОТОВКУ В ПРОВЕДЕНИИ КРАТКОВРЕМЕННЫХ АНТИТАБАЧНЫХ МЕРОПРИЯТИЙ Австралия Да Да Да Да Да Да Бруней-Даруссалам Нет Да Да Нет Нет Нет Вануату Да Нет Да Нет Нет Нет Вьетнам Нет Да Да Да Да Нет Камбоджа Да Нет Нет Нет Нет Нет Кирибати Нет Нет Да Нет Нет Нет Китай Да Да Да Нет Нет Да Лаосская Народно-Демократическая Республика Нет Нет Да Нет Нет Нет Малайзия Да Да Да Нет Нет Нет Маршалловы Острова Нет Нет Да Нет Нет Нет Микронезия (Федеративные Штаты) Нет Нет Да Нет Нет Нет Монголия Нет Нет Да Нет Нет Нет Науру Нет Нет Нет Нет Нет Нет Ниуэ Нет Нет Нет Нет Нет Нет Новая Зеландия Нет Да Да Да Да Да Острова Кука Да Да Да Нет Нет Нет Палау Нет Нет Да Нет Нет Нет Папуа-Новая Гвинея Да Нет Да Нет Нет Нет Республика Корея Да Нет Да Нет Да Да Самоа Нет Нет Нет Нет Нет Нет Сингапур Да Да Да Нет Да Нет Соломоновы Острова Нет Нет Да Нет Нет Нет Тонга Нет Нет Да Нет Да Да Тувалу Нет Нет Да Нет Нет Нет Фиджи Нет Нет Да Нет Нет Нет Филиппины Да Да Да Нет Нет Нет Япония Нет Нет Нет Нет Нет Да 182 183ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В Приложении III содержится информация о годе, в котором соответствующие страны добились наивысшего уровня достижений в реализации пяти мер MPOWER. Данные представлены отдельно по каждому региону ВОЗ. Самым ранним годом проведения оценки показателя «Мониторинг употребления табака» является 2007 год. Тем не менее, не исключено, что в то время как 2007 год указывается некоторыми странами как год наивысших достижений, они на самом деле могли достичь этого уровня ранее. ГОД НАИВЫСШЕГО УРОВНЯ ДОСТИЖЕНИЙ В РЕАЛИЗАЦИИ ОТДЕЛЬНЫХ МЕР БОРЬБЫ ПРОТИВ ТАБАКА ПРИЛОЖЕНИЕ III: Годы наивысшего уровня достижений в реализации меры MPOWER «Повышение налогов на табачные изделия» не включены в это приложение. Доля налогов в цене табачных изделий зависит как от налоговой политики, так и от факторов, касающихся спроса и предложения, которые влияют на производство и розничные цены. Страны, в которых повышались налоги, могли заметить, что доля налога осталась неизменной или даже снизилась при таком же или даже более высоком росте цен, не связанном с налогами, что затрудняло определение года наивысших достижений. Более подробная информация о расчете долей налогов представлена в Техническом примечании III. 184 185ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. Таблица 3.1 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Африки Африка СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Алжир Ангола Бенин 2017 2017 Ботсвана Буркина-Фасо 2010 2015 Бурунди 2018 Габон Гамбия 2018 2018 Гана 2012 Гвинея-Бисау Гвинея 2012 Демократическая Республика Конго 2018 8 Замбия Зимбабве Кабо-Верде Камерун 2018 8 Кения 2007 Коморские Острова Конго 2012 2018 Кот-д’Ивуар Лесото Либерия Маврикий 2008 2008 Мавритания Мадагаскар 2013 2012 2003 Малави Мали Мозамбик Намибия 2010 2013 Нигер 2006 Нигерия 2015 Объединенная Республика Танзания Руанда Сан-Томе и Принсипи Сейшельские Острова 2009 2012 2009 Сенегал 2016 2016 2016 Сьерра-Леоне Того 2012 Уганда 2015 2015 Центральноафриканская Республика Чад 2010 2015 2010 Экваториальная Гвинея Эритрея 2004 Эсватини Эфиопия Южная Африка Южный Судан 186 187ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. * Или более ранний год. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. Таблица 3.2 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Америки Америка СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Антигуа и Барбуда 2018 2018 Аргентина 2011 2012 Багамские Острова 2018 Барбадос 2010 2017 Белиз Боливия (Многонациональное Государство) 2009 Бразилия 2015 2011 2002 2003 2011 Венесуэла (Боливарианская Республика) 2011 2004 Гаити Гайана 2017 2018 8 2017 Гватемала 2008 Гондурас 2010 2017 Гренада Доминика Доминиканская Республика Канада 2007* 2007 2008 2011 Колумбия 2008 2009 Коста-Рика 2007* 2012 2013 Куба Мексика 2013 2009 Никарагуа Панама 2012 2008 2005 2008 Парагвай Перу 2007* 2010 2011 Сальвадор 2015 2016 2011 Сент-Винсент и Гренадины Сент-Китс и Невис Сент-Люсия 2017 Соединенные Штаты Америки 2007* 2008 Суринам 2018 2013 2016 2013 Тринидад и Тобаго 2009 2013 8 Уругвай 2007* 2005 2005 2014 Чили 2007* 2013 2006 Эквадор 2016 2011 2012 Ямайка 2013 2016 2013 188 189ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. * Или более ранний год. Таблица 3.3 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Юго- Восточной Азии Юго-Восточная Азия СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Бангладеш 2014 2015 Бутан 2014 Индия 2016 2016 Индонезия 2015 Корейская Народно-Демократическая Республика Мальдивские Острова 2010 Мьянма 2015 Непал 2011 2011 2014 Таиланд 2007* 2010 2005 Тимор-Лешти 2018 Шри-Ланка 2012 190 191ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. * Или более ранний год. Таблица 3.4 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Европы Европа СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Австрия 2007* 2016 Азербайджан 2016 2017 Албания 2006 2006 Андорра Армения 2007* 2016 Беларусь 2016 Бельгия 2007* 2016 Болгария 2007* 2012 2016 Босния и Герцеговина Венгрия 2007* 2016 Германия 2007* 2016 Греция 2007* 2010 2016 Грузия 2007* 2018 Дания 2007* 2011 2016 Израиль Ирландия 2007* 2004 2003 2016 Исландия 2007* Испания 2007* 2010 2017 2010 Италия 2007* 2016 Казахстан 2007* 2014 Кипр 2017 Киргизия 2014 Латвия 2007* 2016 Литва 2007* 2016 Люксембург 2007* 2016 2017 Мальта 2007* 2010 2016 Молдова 2013 2016 2016 Монако Нидерланды 2007* 2014 2016 Норвегия 2007* 2013 Польша 2007* 2016 Португалия 2007* 2015 Российская Федерация 2007* 2013 2014 2013 Румыния 2007* 2015 2016 Сан-Марино Северная Македония 2008 Сербия 2007* Словакия 2007* 2018 2016 Словения 2007* 2017 2017 Соединенное Королевство Великобритании и Северной Ирландии 2007* 2006 2016 Таджикистан 2018 Туркменистан 2000 2014 Турция 2007* 2008 2010 2012 2012 Узбекистан Украина 2007* 2009 Финляндия 2007* 2016 Франция 2007* 2016 Хорватия 2007* 2017 Черногория Чешская Республика 2007* 2018 2016 Швейцария 2007* Швеция 2007* 2018 2016 Эстония 2007* 2016 192 193ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. * Или более ранний год. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. < Термин «Западный берег реки Иордан и сектор Газа» используется как синоним для обозначения оккупированной палестинской территории, включая восточный Иерусалим. Таблица 3.5 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Восточного Средиземноморья Восточное Средиземноморье СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Афганистан 2015 2015 Бахрейн 2011 Джибути 2008 2007 Египет 2007* 2010 2008 Западный берег реки Иордан и сектор Газа < 2011 Иордания Ирак Иран (Исламская Республика) 2007* 2007 2008 2007 Йемен 2013 Катар 2014 2016 Кувейт 2007* 2012 2016 Ливан 2013 2011 Ливия 2009 2009 Марокко Объединенные Арабские Эмираты 2008 2013 Оман Пакистан 2014 2009 2017 8 Саудовская Аравия 2018 2017 8 2017 Сирийская Арабская Республика Сомали Судан Тунис 194 195ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Примечание: Пустая ячейка указывает на то, что население не охвачено мерой с наивысшим уровнем ее реализации. * Или более ранний год. 8 Стратегия принята, но не реализована к 31 декабря 2018 года. Таблица 3.6 Год наивысшего уровня достижений в реализации отдельных мер борьбы против табака в странах Западной части Тихого океана Западная часть Тихого океана СТРАНА ГОД ДОСТИЖЕНИЯ НАИВЫСШЕГО УРОВНЯ В РЕАЛИЗАЦИИ МЕР MPOWER МОНИТОРИНГ УПОТРЕБЛЕНИЯ ТАБАКА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ Австралия 2007* 2005 2011 2004 Бруней-Даруссалам 2014 2012 2007 Вануату 2013 2008 Вьетнам 2014 2013 Камбоджа 2014 2016 2016 Кирибати 2013 Китай Лаосская Народно-Демократическая Республика 2015 2016 2016 Малайзия 2012 2008 Маршалловы Острова 2006 Микронезия (Федеративные Штаты) Монголия 2007* 2012 2012 Науру 2009 Ниуэ 2018 8 2018 8 Новая Зеландия 2007* 2003 2000 2007 Острова Кука 2007* Палау 2010 Папуа-Новая Гвинея 2012 Республика Корея 2007* 2006 Самоа 2013 Сингапур 2007* 1999 2012 Соломоновы Острова 2013 Тонга Тувалу 2008 Фиджи 2013 Филиппины 2007* 2014 Япония 2007* 196 197ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В Приложении IV представлена информация об охвате населения 100 крупнейших городов мира отдельными мерами борьбы против табака с наивысшим уровнем их реализации. Города перечислены в алфавитном порядке. Есть много способов установить географические границы и определить размеры «города». Для целей настоящего доклада мы сосредоточили внимание на границах юрисдикции городов, так как законы, принятые на субнациональном уровне, будут применяться к населению в пределах юрисдикций. Когда большой «город» включает в себя несколько юрисдикций или части юрисдикций, вполне вероятно, что не каждый житель во всем «городе» охвачен действием одного и того же закона. Поэтому мы используем список городов с численностью их населения, опубликованный в Демографическом ежегоднике Статистического отдела ООН, так как он составлен с разбивкой по юрисдикциям. Исходные данные представлены в таблице 8 по адресу: https://unstats.un.org/unsd/demographic- social/products/dyb/dyb_2016/ НАИВЫСШИЙ УРОВЕНЬ ДОСТИЖЕНИЙ В РЕАЛИЗАЦИИ ОТДЕЛЬНЫХ МЕР БОРЬБЫ ПРОТИВ ТАБАКА В 100 КРУПНЕЙШИХ ГОРОДАХ МИРА ПРИЛОЖЕНИЕ IV: Ряд стран не фигурирует в таблице 8 Демографического ежегодника, поскольку они не представили данные. Страны, отсутствующие в списке по причине непредставления данных, но достаточно большие, чтобы потенциально претендовать на включение в список 100 крупнейших городов: Ангола, Вьетнам, Демократическая Республика Конго, Нигерия, Судан и Чад. Определение наивысшего уровня достижений дается в Техническом примечании I. 198 199ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 4.1 Наивысший уровень достижений в реализации отдельных мер борьбы против табака в 100 крупнейших городах мира ГОРОД * ЧИСЛЕННОСТЬ НАСЕЛЕНИЯ (2016 ГОД) ОХВАТ МЕРАМИ С НАИВЫСШИМ УРОВНЕМ ИХ РЕАЛИЗАЦИИ СТРАНА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ ПОВЫШЕНИЕ НАЛОГОВ НА ТАБАЧНЫЕ ИЗДЕЛИЯ Абиджан 4 395 243 Кот-д’Ивуар Адана 2 183 167 N N N N N Турция Аддис-Абеба 2 979 086 N Эфиопия Александрия 4 358 439 N N N Египет Алеппо 4 450 000 Сирийская Арабская Республика Алжир 2 712 944 Алжир Амман 3 752 644 N N Иордания Анкара 5 270 575 N N N N N Турция Анталия 2 288 456 N N N N N Турция Ахмадабад 5 633 927 N N Индия Баку 2 215 034 N N Азербайджан Бангалор 8 495 492 N N Индия Бангкок 8 305 218 N N Таиланд Бандунг 2 497 938 C Индонезия Белу-Оризонти 2 513 451 N N N N N Бразилия Берлин 3 520 031 N Германия Богота 7 980 001 N N N Колумбия Бразилиа 2 977 216 N N N N N Бразилия Брисбен 2 209 453 S N N N Австралия Бурса 2 842 547 N N N N N Турция Буэнос-Айрес 13 879 707 N N N Аргентина Гвадалахара 4 853 425 N N Мексика Гиза 3 122 041 N N N Египет Гонконг (Китай, САР) 7 336 600 C C C Китай, САР Гонконг Гуаякиль 2 531 371 N N Эквадор Дакка 8 906 035 N Бангладеш Дамаск, сельские районы 2 529 000 Сирийская Арабская Республика Дар-эс-Салам 4 364 541 Объединенная Республика Танзания Дели 11 034 555 N N Индия Джайпур 3 046 163 N N Индия Джакарта 10 374 235 N Индонезия Джидда 3 430 697 N N Саудовская Аравия Дуала 2 948 464 N Камерун Измир 4 168 415 N N N N N Турция Инчхон 2 914 455 N Республика Корея Иокогама 3 724 844 Япония Кабул 3 817 241 N N Афганистан Каир 7 248 671 N N N Египет Кали 2 394 925 N N N Колумбия Калькутта 4 496 694 N N Индия Канпур 2 768 057 N N Индия Карачи 9 339 023 N N Пакистан Касабланка 3 352 399 Марокко Кесон-Сити 2 936 116 N Филиппины Киев 2 803 716 N Украина Конья 2 130 544 N N N N N Турция Лакхнау 2 817 105 N N Индия Лахор 5 143 495 N N 8 Пакистан Лима 10 039 455 N N Перу Лондон 8 135 667 N C N N Соединенное Королевство Великобритании и Северной Ирландии Лос-Анджелес 3 976 322 S N Соединенные Штаты Америки Примечания: Пустая ячейка указывает на то, что население соответствующего города не охвачено мерой с наивысшим уровнем ее реализации. Определение наивысшего уровня достижений в реализации соответствующей меры дается в Техническом примечании I. * Только города, вошедшие в список 100 самых крупных городов по численности населения, по данным Демографического ежегодника Статистического отдела ООН за 2016 год (доступны по ссылке: https://unstats.un.org/unsd/demographic-social/products/dyb/ documents/dyb2016/table08.xls). 8 Стратегия принята, но не реализована к 31 декабря 2018 года. Население города охвачено национальным законодательством или политикой на наивысшем уровне достижений Населения города охвачено законодательством или политикой, принятыми на уровне штата, на наивысшем уровне достижений Население города охвачено законодательством или политикой, принятыми на уровне города, на наивысшем уровне достижений N S C 200 201ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 4.1 Наивысший уровень достижений в реализации отдельных мер борьбы против табака в 100 крупнейших городах мира (продолжение) Население города охвачено национальным законодательством или политикой на наивысшем уровне достижений Населения города охвачено законодательством или политикой, принятыми на уровне штата, на наивысшем уровне достижений Население города охвачено законодательством или политикой, принятыми на уровне города, на наивысшем уровне достижений N S C Примечания: Пустая ячейка указывает на то, что население соответствующего города не охвачено мерой с наивысшим уровнем ее реализации. Определение наивысшего уровня достижений в реализации соответствующей меры дается в Техническом примечании I. * Только города, вошедшие в список 100 самых крупных городов по численности населения, по данным Демографического ежегодника Статистического отдела ООН за 2016 год (доступны по ссылке: https://unstats.un.org/unsd/demographic-social/products/dyb/ documents/dyb2016/table08.xls). 8 Стратегия принята, но не реализована к 31 декабря 2018 года. ГОРОД * ЧИСЛЕННОСТЬ НАСЕЛЕНИЯ (2016 ГОД) ОХВАТ МЕРАМИ С НАИВЫСШИМ УРОВНЕМ ИХ РЕАЛИЗАЦИИ СТРАНА ЗАЩИТА ЛЮДЕЙ ОТ ТАБАЧНОГО ДЫМА ПРЕДЛОЖЕНИЕ ПОМОЩИ В ЦЕЛЯХ ПРЕКРАЩЕНИЯ УПОТРЕБЛЕНИЯ ТАБАКА ПРЕДУПРЕЖДЕНИЕ ОБ ОПАСНОСТЯХ, СВЯЗАННЫХ С ТАБАКОМ ОБЕСПЕЧЕНИЕ СОБЛЮДЕНИЯ ЗАПРЕТОВ НА РЕКЛАМУ, СТИМУЛИРОВАНИЕ ПРОДАЖИ И СПОНСОРСТВО ТАБАЧНЫХ ИЗДЕЛИЙ ПОВЫШЕНИЕ НАЛОГОВ НА ТАБАЧНЫЕ ИЗДЕЛИЯ Мадрид 3 186 241 N N N N Испания Мванза 2 772 509 Объединенная Республика Танзания Медан 2 247 425 C Индонезия Медельин 2 486 723 N N N Колумбия Мельбурн 4 353 514 S N N N Австралия Мехико 21 497 029 S N N Мексика Мешхед 2 766 258 N N N Иран (Исламская Республика) Монтеррей 4 540 429 S N N Мексика Москва 11 918 057 N N N Российская Федерация Мумбаи 12 442 373 N N Индия Нагоя 2 295 638 Япония Нагпур 2 405 665 N N Индия Найроби 3 133 518 N Кения Нью-Йорк 8 537 673 N Соединенные Штаты Америки Осака 2 691 185 Япония Париж 2 243 833 N N N Франция Пекин 19 610 000 N Китай Пуна 3 124 458 N N Индия Пусан 3 388 631 N Республика Корея Пуэбла-Тласкала 2 986 825 N N Мексика Пхеньян 2 581 076 Корейская Народно- Демократическая Республика Рим 2 867 672 N N N Италия Рио-де-Жанейро 6 498 837 N N N N N Бразилия Сальвадор 2 938 092 N N N N N Бразилия Сан-Паулу 12 038 175 N N N N N Бразилия Санкт-Петербург 4 990 602 N N N Российская Федерация Сантьяго 5 561 252 N N N Чили Сеул 9 834 687 N Республика Корея Сидней 4 526 479 N N N N Австралия Сингапур 5 607 283 N N Сингапур Стамбул 14 657 434 N N N N N Турция Сурабая 2 874 699 Индонезия Сурат 4 501 610 N N Индия Тангеранг 2 139 891 Индонезия Ташкент 2 393 176 Узбекистан Тегеран 8 154 051 N N N Иран (Исламская Республика) Токио 9 272 740 Япония Толука 2 225 286 S N N Мексика Торонто 2 876 095 N N N Канада Тэгу 2 449 667 N Республика Корея Форталеза 2 609 716 N N N N N Бразилия Хайдарабад 6 993 262 S N N Индия Хьюстон 2 303 482 N Соединенные Штаты Америки Ченнаи 4 646 732 N N Индия Чикаго 2 704 958 N Соединенные Штаты Америки Читтагонг 2 591 681 N Бангладеш Эр-Рияд 5 188 286 N N Саудовская Аравия Янгон 5 209 541 Мьянма Яунде 2 873 567 N 8 Камерун 202 203ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД В Приложении V показан статус Рамочной конвенции ВОЗ по борьбе против табака (РКБТ ВОЗ). Ратификация представляет собой международный акт, которым страны, уже подписавшие конвенцию, официально заявляют о своем согласии признать ее обязательность для себя. Присоединение представляет собой международный акт, которым страны, не подписавшие договор/соглашение, официально заявляют о своем согласии признать их обязательность для себя. Принятие и утверждение представляют собой правовые процедуры, эквивалентные ратификации. Подписание конвенции означает, что страна юридически не связана обязательствами по договору, но обязана не подрывать ее положений. СТАТУС РАМОЧНОЙ КОНВЕНЦИИ ВОЗ ПО БОРЬБЕ ПРОТИВ ТАБАКА ПРИЛОЖЕНИЕ V: РКБТ ВОЗ вступила в силу 27 февраля 2005 года. Договор остается открытым для ратификации, принятия, утверждения, официального одобрения и присоединения в течение неограниченного срока для государств и соответствующих региональных организаций экономической интеграции, желающих стать его участниками. 204 205ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 5.1 Статус Рамочной конвенции ВОЗ по борьбе против табака, по состоянию на 8 мая 2019 года СТРАНА ДАТА ПОДПИСАНИЯ ДАТА РАТИФИКАЦИИ* (ИЛИ ЮРИДИЧЕСКИ ЭКВИВАЛЕНТНОЙ ПРОЦЕДУРЫ) Австралия 5 декабря 2003 г. 27 октября 2004 г. Австрия 28 августа 2003 г. 15 сентября 2005 г. Азербайджан 1 ноября 2005 г. a Албания 29 июня 2004 г. 26 апреля 2006 г. Алжир 20 июня 2003 г. 30 июня 2006 г. Ангола 29 июня 2004 г. 20 сентября 2007 г. Андорра Антигуа и Барбуда 28 июня 2004 г. 5 июня 2006 г. Аргентина 25 сентября 2003 г. Армения 29 ноября 2004 г. a Афганистан 29 июня 2004 г. 13 августа 2010 г. Багамские Острова 29 июня 2004 г. 3 ноября 2009 г. Бангладеш 16 июня 2003 г. 14 июня 2004 г. Барбадос 28 июня 2004 г. 3 ноября 2005 г. Бахрейн 20 марта 2007 г. a Беларусь 17 июня 2004 г. 8 сентября 2005 г. Белиз 26 сентября 2003 г. 15 декабря 2005 г. Бельгия 22 января 2004 г. 1 ноября 2005 г. Бенин 18 июня 2004 г. 3 ноября 2005 г. Болгария 22 декабря 2003 г. 7 ноября 2005 г. Боливия (Многонациональное Государство) 27 февраля 2004 г. 15 сентября 2005 г. Босния и Герцеговина 10 июля 2009 г. Ботсвана 16 июня 2003 г. 31 января 2005 г. Бразилия 16 июня 2003 г. 3 ноября 2005 г. Бруней-Даруссалам 3 июня 2004 г. 3 июня 2004 г. Буркина-Фасо 22 декабря 2003 г. 31 июля 2006 г. Бурунди 16 июня 2003 г. 22 ноября 2005 г. Бутан 9 декабря 2003 г. 23 августа 2004 г. Вануату 22 апреля 2004 г. 16 сентября 2005 г. Венгрия 16 июня 2003 г. 7 апреля 2004 г. Венесуэла (Боливарианская Республика) 22 сентября 2003 г. 27 июня 2006 г. Вьетнам 3 сентября 2003 г. 17 декабря 2004 г. Габон 22 августа 2003 г. 20 февраля 2009 г. Гайана 15 сентября 2005 г. a Гаити 23 июля 2003 г. Гамбия 16 июня 2003 г. 18 сентября 2007 г. Гана 20 июня 2003 г. 29 ноября 2004 г. Гватемала 25 сентября 2003 г. 16 ноября 2005 г. Гвинея 1 апреля 2004 г. 7 ноября 2007 г. Гвинея-Бисау 7 ноября 2008 г. a Германия 24 октября 2003 г. 16 декабря 2004 г. Гондурас 18 июня 2004 г. 16 февраля 2005 г. Гренада 29 июня 2004 г. 14 августа 2007 г. Греция 16 июня 2003 г. 27 января 2006 г. Грузия 20 февраля 2004 г. 14 февраля 2006 г. Дания 16 июня 2003 г. 16 декабря 2004 г. Демократическая Республика Конго 28 июня 2004 г. 28 октября 2005 г. Джибути 13 мая 2004 г. 31 июля 2005 г. Доминика 29 июня 2004 г. 24 июля 2006 г. Доминиканская Республика * Ратификация представляет собой международный акт, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. a Присоединение представляет собой международный акт, которым страны, не подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. A Принятие представляет собой международный акт, аналогичный ратификации, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. AA Утверждение представляет собой международный акт, аналогичный ратификации, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. c Официальное подтверждение представляет собой международный акт, соответствующий ратификации государством, которым международная организация (в случае РКБТ ВОЗ – компетентные региональные организации экономической интеграции) официально заявляют о своем согласии на его/ее обязательность для себя. d Правопреемство представляет собой международный акт, независимо от формулировки или названия, которым государства-правопреемники официально заявляют о своем согласии на обязательность для себя договоров/конвенций, первоначально заключенных государством, являющимся их правопредшественником. СТРАНА ДАТА ПОДПИСАНИЯ ДАТА РАТИФИКАЦИИ* (ИЛИ ЮРИДИЧЕСКИ ЭКВИВАЛЕНТНОЙ ПРОЦЕДУРЫ) Европейское сообщество 16 июня 2003 г. 30 июня 2005 г. c Египет 17 июня 2003 г. 25 февраля 2005 г. Замбия 23 мая 2008 г. a Зимбабве Йемен 20 июня 2003 г. 22 февраля 2007 г. Израиль 20 июня 2003 г. 24 августа 2005 г. Индия 10 сентября 2003 г. 5 февраля 2004 г. Индонезия Иордания 28 мая 2004 г. 19 августа 2004 г. Ирак 29 июня 2004 г. 17 марта 2008 г. Иран (Исламская Республика) 16 июня 2003 г. 6 ноября 2005 г. Ирландия 16 сентября 2003 г. 7 ноября 2005 г. Исландия 16 июня 2003 г. 14 июня 2004 г. Испания 16 июня 2003 г. 11 января 2005 г. Италия 16 июня 2003 г. 2 июля 2008 г. Кабо-Верде 17 февраля 2004 г. 4 октября 2005 г. Казахстан 21 июня 2004 г. 22 января 2007 г. Камбоджа 25 мая 2004 г. 15 ноября 2005 г. Камерун 13 мая 2004 г. 3 февраля 2006 г. Канада 15 июля 2003 г. 26 ноября 2004 г. Катар 17 июня 2003 г. 23 июля 2004 г. Кения 25 июня 2004 г. 25 июня 2004 г. Кипр 24 мая 2004 г. 26 октября 2005 г. Кирибати 27 апреля 2004 г. 15 сентября 2005 г. Китай 10 ноября 2003 г. 11 октября 2005 г. Колумбия 10 апреля 2008 г. a Коморские Острова 27 февраля 2004 г. 24 января 2006 г. Конго 23 марта 2004 г. 6 февраля 2007 г. Корейская Народно-Демократическая Республика 17 июня 2003 г. 27 апреля 2005 г. Коста-Рика 3 июля 2003 г. 21 августа 2008 г. Кот-д’Ивуар 24 июля 2003 г. 13 августа 2010 г. Куба 29 июня 2004 г. Кувейт 16 июня 2003 г. 12 мая 2006 г. Кыргызстан 18 февраля 2004 г. 25 мая 2006 г. Лаосская Народно-Демократическая Республика 29 июня 2004 г. 6 сентября 2006 г. Латвия 10 мая 2004 г. 10 февраля 2005 г. Лесото 23 июня 2004 г. 14 января 2005 г. Либерия 25 июня 2004 г. 15 сентября 2009 г. Ливан 4 марта 2004 г. 7 декабря 2005 г. Ливия 18 июня 2004 г. 7 июня 2005 г. Литва 22 сентября 2003 г. 16 декабря 2004 г. Люксембург 16 июня 2003 г. 30 июня 2005 г. Маврикий 17 июня 2003 г. 17 мая 2004 г. Мавритания 24 июня 2004 г. 28 октября 2005 г. Мадагаскар 24 сентября 2003 г. 22 сентября 2004 г. Малави Малайзия 23 сентября 2003 г. 16 сентября 2005 г. Мали 23 сентября 2003 г. 19 октября 2005 г. Мальдивские Острова 17 мая 2004 г. 20 мая 2004 г. Мальта 16 июня 2003 г. 24 сентября 2003 г. 206 207ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Таблица 5.1 Статус Рамочной конвенции ВОЗ по борьбе против табака, по состоянию на 8 мая 2019 года (продолжение) * Ратификация представляет собой международный акт, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. a Присоединение представляет собой международный акт, которым страны, не подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. A Принятие представляет собой международный акт, аналогичный ратификации, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. AA Утверждение представляет собой международный акт, аналогичный ратификации, которым страны, уже подписавшие договор/конвенцию, официально заявляют о своем согласии на его/ее обязательность для себя. c Официальное подтверждение представляет собой международный акт, соответствующий ратификации государством, которым международная организация (в случае РКБТ ВОЗ – компетентные региональные организации экономической интеграции) официально заявляют о своем согласии на его/ее обязательность для себя. d Правопреемство представляет собой международный акт, независимо от формулировки или названия, которым государства-правопреемники официально заявляют о своем согласии на обязательность для себя договоров/конвенций, первоначально заключенных государством, являющимся их правопредшественником. СТРАНА ДАТА ПОДПИСАНИЯ ДАТА РАТИФИКАЦИИ* (ИЛИ ЮРИДИЧЕСКИ ЭКВИВАЛЕНТНОЙ ПРОЦЕДУРЫ) Марокко 16 апреля 2004 г. Маршалловы Острова 16 июня 2003 г. 8 декабря 2004 г. Мексика 12 августа 2003 г. 28 мая 2004 г. Микронезия (Федеративные Штаты) 28 июня 2004 г. 18 марта 2005 г. Мозамбик 18 июня 2003 г. Монако Монголия 16 июня 2003 г. 27 января 2004 г. Мьянма 23 октября 2003 г. 21 апреля 2004 г. Намибия 29 января 2004 г. 7 ноября 2005 г. Науру 29 июня 2004 г. a Непал 3 декабря 2003 г. 7 ноября 2006 г. Нигер 28 июня 2004 г. 25 августа 2005 г. Нигерия 28 июня 2004 г. 20 октября 2005 г. Нидерланды 16 июня 2003 г. 27 января 2005 г. A Никарагуа 7 июня 2004 г. 9 апреля 2008 г. Ниуэ 18 июня 2004 г. 3 июня 2005 г. Новая Зеландия 16 июня 2003 г. 27 января 2004 г. Норвегия 16 июня 2003 г. 16 июня 2003 г. AA Объединенная Республика Танзания 27 января 2004 г. 30 апреля 2007 г. Объединенные Арабские Эмираты 24 июня 2004 г. 7 ноября 2005 г. Оман 9 марта 2005 г. a Острова Кука 14 мая 2004 г. 14 мая 2004 г. Пакистан 18 мая 2004 г. 3 ноября 2004 г. Палау 16 июня 2003 г. 12 февраля 2004 г. Панама 26 сентября 2003 г. 16 августа 2004 г. Папуа-Новая Гвинея 22 июня 2004 г. 25 мая 2006 г. Парагвай 16 июня 2003 г. 26 сентября 2006 г. Перу 21 апреля 2004 г. 30 ноября 2004 г. Польша 14 июня 2004 г. 15 сентября 2006 г. Португалия 9 января 2004 г. 8 ноября 2005 г. AA Республика Корея 21 июля 2003 г. 16 мая 2005 г. Республика Молдова 29 июня 2004 г. 3 февраля 2009 г. a Российская Федерация 3 июня 2008 г. a Руанда 2 июня 2004 г. 19 октября 2005 г. Румыния 25 июня 2004 г. 27 января 2006 г. Сальвадор 18 марта 2004 г. Самоа 25 сентября 2003 г. 3 ноября 2005 г. Сан-Марино 26 сентября 2003 г. 7 июля 2004 г. Сан-Томе и Принсипи 18 июня 2004 г. 12 апреля 2006 г. Саудовская Аравия 24 июня 2004 г. 9 мая 2005 г. Северная Македония 30 июня 2006 г. a Сейшельские Острова 11 сентября 2003 г. 12 ноября 2003 г. Сенегал 19 июня 2003 г. 27 января 2005 г. Сент-Винсент и Гренадины 14 июня 2004 г. 29 октября 2010 г. Сент-Китс и Невис 29 июня 2004 г. 21 июня 2011 г. Сент-Люсия 29 июня 2004 г. 7 ноября 2005 г. Сербия 28 июня 2004 г. 8 февраля 2006 г. Сингапур 29 декабря 2003 г. 14 мая 2004 г. Сирийская Арабская Республика 11 июля 2003 г. 22 ноября 2004 г. Словакия 19 декабря 2003 г. 4 мая 2004 г. СТРАНА ДАТА ПОДПИСАНИЯ ДАТА РАТИФИКАЦИИ* (ИЛИ ЮРИДИЧЕСКИ ЭКВИВАЛЕНТНОЙ ПРОЦЕДУРЫ) Словения 25 сентября 2003 г. 15 марта 2005 г. Соединенное Королевство Великобритании и Северной Ирландии 16 июня 2003 г. 16 декабря 2004 г. Соединенные Штаты Америки 10 мая 2004 г. Соломоновы Острова 18 июня 2004 г. 10 августа 2004 г. Сомали Судан 10 июня 2004 г. 31 октября 2005 г. Суринам 24 июня 2004 г. 16 декабря 2008 г. Сьерра-Леоне 22 мая 2009 г. Таджикистан Таиланд 20 июня 2003 г. 8 ноября 2004 г. Тимор-Лешти 25 мая 2004 г. 22 декабря 2004 г. Того 12 мая 2004 г. 15 ноября 2005 г. Тонга 25 сентября 2003 г. 8 апреля 2005 г. Тринидад и Тобаго 27 августа 2003 г. 19 августа 2004 г. Тувалу 10 июня 2004 г. 26 сентября 2005 г. Тунис 22 августа 2003 г. 7 июня 2010 г. Туркменистан 13 мая 2011 г. Турция 28 апреля 2004 г. 31 декабря 2004 г. Уганда 5 марта 2004 г. 20 июня 2007 г. Узбекистан 15 мая 2012 г. Украина 25 июня 2004 г. 6 июня 2006 г. Уругвай 19 июня 2003 г. 9 сентября 2004 г. Фиджи 3 октября 2003 г. 3 октября 2003 г. Филиппины 23 сентября 2003 г. 6 июня 2005 г. Финляндия 16 июня 2003 г. 24 января 2005 г. Франция 16 июня 2003 г. 19 октября 2004 г. AA Хорватия 2 июня 2004 г. 14 июля 2008 г. Центральноафриканская Республика 29 декабря 2003 г. 7 ноября 2005 г. Чад 22 июня 2004 г. 30 января 2006 г. Черногория 23 октября 2006 г. d Чешская Республика 16 июня 2003 г. 1 июня 2012 г. Чили 25 сентября 2003 г. 13 июня 2005 г. Швейцария 25 июня 2004 г. Швеция 16 июня 2003 г. 7 июля 2005 г. Шри-Ланка 23 сентября 2003 г. 11 ноября 2003 г. Эквадор 22 марта 2004 г. 25 июля 2006 г. Экваториальная Гвинея 17 сентября 2005 г. a Эритрея Эсватини 29 июня 2004 г. 13 января 2006 г. Эстония 8 июня 2004 г. 27 июля 2005 г. Эфиопия 25 февраля 2004 г. Южно-Африканская Республика 16 июня 2003 г. 19 апреля 2005 г. Ямайка 24 сентября 2003 г. 7 июля 2005 г. Япония 9 марта 2004 г. 8 июня 2004 г. A Источник: веб-сайт «Собрание договоров Организации Объединенных Наций» https://treaties.un.org/pages/ViewDetails. aspx?src=TREATY&mtdsg_НЕТ=IX-4&chapter=9&lang=en, по состоянию на 8 мая 2019 года). Хотя Лихтенштейн и не является государством-членом ВОЗ, он как государство-член Организации Объединенных Наций имеет право присоединиться к РКБТ ВОЗ. Тем не менее, данное государство не предприняло никаких шагов в этом направлении. При представлении документов на присоединение к РКБТ ВОЗ некоторые Стороны включили в них уведомления и/или декларации. Все уведомления доступны по ссылке: https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_НЕТ=IX- 4&chapter=9&lang=en 208 209ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД ДОКЛАД ВОЗ О ГЛОБАЛЬНОЙ ТАБАЧНОЙ ЭПИДЕМИИ, 2019 ГОД Silva из Секретариата Рамочной конвенции по борьбе против табака Всемирной организации здравоохранения за их вклад в подготовку многих глав настоящего доклада, а также за их общие комментарии по проекту доклада. Hebe Naomi Gouda координировала выпуск настоящего доклада при поддержке со стороны Kerstin Schotte, а также с помощью Alexandra Choi и Pirathap Loganathan. Административную поддержку обеспечили: Amal Amoune-Naal, Miriamjoy Aryee-Quansah, Gareth Burns, Rosane De Barros Serrao, Luis Madge, Zahra Ali Piazza, Ochid Romzi, Florence Taylor и Elizabeth Tecson. Priyanka Dahiya и Marine Perraudin отвечали за оценку и анализ законодательства стран при поддержке Kritika Khanijo, Rebecca Röttger и Anastasia Vernikou. Управление данными, их анализ, формирование таблиц, графиков и приложений были выполнены Alison Commar при поддержке Soothesuk Kusumpa и Elza Anna Barzdina. Оценки распространенности курения были произведены Alison Commar в сотрудничестве с Ver Bilano и Edouard Tursan d’Espaignet. Данные о прекращении употребления табака были обновлены Dongbo Fu при поддержке Bowei Huang, Merideth Lewis- Cooney, Alexandra Choi и Tuba Asvar. Неоценимый вклад в подготовку главы «Предложение помощи в целях прекращения употребления табака» внесли Heba Ayoub, Annette M David, Madmoud M Elhabiby, Elba Esteves, Tom Glynn, Christina Gratziou, Takashi Hanioka, Feras Hawari, Taylor Hays, Gholamreza Heydari, Sonali Jhanjee, Katherine E Kemper, Min Kyung Lim, Tim McAfee, Pratima Murthy, Yvonne Olando, Jennifer Percival, Olivier Randriamahazosoa, Martin Raw, Галина Сахарова, Etta Short, Ken Wassum, Dan Xiao, Jintana Yunibhand. Мы также благодарим Katherine Deland за подготовку главы «Рамочная конвенция ВОЗ по борьбе против табака и Протокол о ликвидации незаконной торговли табачными изделиями». Jorge Alday, Anna Gilmore, Maciej Goniewicz, Brian King и Gan Quan внесли значительный вклад в освещение некоторых других аспектов доклада. Финансово-экономический обзор и анализ, включая налогообложение табачных изделий и цены, были проведены Anne-Marie Perucic и Robert Totanes при поддержке Mark Goodchild, Roberto Iglesias, Dora Nicolazzo и Alejandro Ramos. Данные о налогах и ценах были собраны при поддержке чиновников из министерств финансов и министерств здравоохранения, а также Luk Joossens и Константина Красовского. Мы выражаем признательность Jennifer Ellis, Kelly Henning и Adrienne Pizatella из Инициативы Блумберга по сокращению потребления табачных изделий за их сотрудничество. Мы также благодарим Florence Rusciano за предоставленные карты. Мы также выражаем благодарность Институту глобальной борьбы против табака при Медицинской школе Блумберга Университета имени Джонса Хопкинса, и в частности Joanna Cohen и Kevin Welding. Мы также хотели бы поблагодарить Vital Strategies за их сотрудничество в сборе и анализе данных об антитабачных кампаниях в СМИ, и в частности Therese Buendia, Christina Curell и Алексея Котова, а также: Luiza Amorim, Ilona van de Braak, Tom Carroll, Tuba Durgut, Carlos Garcia, Shafiqul Islam, Ziauddin Islam, Vaishakhi Mallik, Ирину Морозову, Sandra Mullin, Nandita Murukutla, Nguyen Nhung, Rebecca Perl, Ancha Rachfiansyah, Benjamin Gonzalez Rubio, Md. Nasir Uddin и Winnie Chen Yu. Выражаем также особую благодарность «Кампании за детей, свободных от табака», особенно Maria Carmona, Kaitlin Donley и Monique Muggli, за конструктивный обмен информацией, касающейся вопросов борьбы против табака и соответствующего законодательства. Также благодарим Rob Cunningham из Канадского онкологического общества за предоставление информации в отношении предупредительных надписей о вреде табака для здоровья. Мы благодарим команду из компании Alboum за качественный и быстрый перевод законодательных документов. Vinayak Prasad, Douglas Bettcher и Vera Luizada Costa e Silva проверили весь доклад и дали заключительные комментарии. Особую благодарность выражаем нашим редакторам Aubra Godwin и Angela Burton, а также нашему дизайнеру Jean- Claude Fattier за их эффективную помощь в своевременной публикации данного доклада. Выпуск настоящего документа ВОЗ финансировался за счет средств гранта, предоставленного Благотворительным фондом Bloomberg Philanthropies. Ответственность за содержание настоящего документа лежит целиком на ВОЗ, и оно не отражает позицию Bloomberg Philanthropies. Выражение признательности Всемирная организация здравоохранения выражает глубокую благодарность следующим лицам за их вклад в работу по составлению данного доклада: Региональное бюро ВОЗ для стран Африки: Jean-Marie Dangou, Deowan Mohee, Nivo Ramanandraibe, Noureiny Tcha- Kondor. Региональное бюро ВОЗ для стран Америки: Francisco Armada Perez, Adriana Bacelar Gomes, Itziar Belausteguigoitia, Natalia Parra, Rosa Sandoval. Региональное бюро ВОЗ для стран Юго-Восточной Азии: Jagdish Kaur, Syed Mahfuzul Huq, Tara Mona Kessaram, Arvind Rinkoo (Бангладеш), Kencho Wangdi (Бутан), Atul Dahal, Hye Ran Ri (КНДР), Praveen Sinha, Fikru Tesfaye Tullu (Индия), Farrukh Qureshi, Dina Kania (Индонезия), Fathimath Hudha (Мальдивские Острова), Myo Paing (Мьянма), Lonim Dixit, Md Khurshid Alam Hyder (Непал), Suveendran Thirupathy (Шри-Ланка), Sushera Bunluesin, Renu Garg (Таиланд), Leoneto Pinto (Тимор-Лешти). Европейское региональное бюро ВОЗ: Angela Ciobanu, Елизавета Лебедева, Kristina Mauer-Stender. Региональное бюро ВОЗ для стран Восточного Средиземноморья: Raouf Alebshehy, Fatimah El-Awa, Heba Fouad, Miriam Gordon, Radwa el Wakil. Региональное бюро ВОЗ для стран Западной части Тихого океана: Melanie Aldeon, Ramon de Guzman, Mina Kashiwabara, Kate Lannan, Hai-Rim Shin, Daravuth Yel (Камбоджа), Kelvin Khow Chuan Heng, Jiani Sun (Китай), Ada Moadsiri, Semenson Ehpel, Eunyoung Ko (Федеративные Штаты Микронезии), Pushpanjali Padayachi (Фиджи), Koorio Tetabea (Кирибати), Douangkeo Thochongliachi (Лаосская Народно- Демократическая Республика), Paul Soo, Narwant Kaur (Малайзия), Naranchimeg Jamiyanjamts, Bolormaa Sukhbaatar (Монголия), Anna Maalsen (Папуа-Новая Гвинея), Florante Trinidad (Филиппины), Kolisi Viki (Самоа), Kirsten Frandsen (Соломоновы Острова), Yutaro Setoya (Тонга), Tsogzolmaa Bayandorj (Вануату), Lam Nguyen Tuan, Pham Thi Quynh Nga (Вьетнам). Штаб-квартира ВОЗ в Женеве: Virginia Arnold, Ferranda Cotado, Melanie Cowan, Hicham El-Berri, Ranti Fayokun, Sarah Galbraith-Emami, Marta Guglielmetti, Per Hasvold, Benn McGrady, Jeremias Paul, Leanne Riley, Kate Robertson, Susannah Robinson, Stefan Savin, Ulrike Schwerdtfeger, Simone St Claire, Jean Tesche. Мы выражаем особую благодарность Kelvin Khow Chuan Heng и Vera Luiza da Costa e 210 Фотографии и иллюстрации © Всемирная организация здравоохранения Стр. 20 – Фотограф: Diego Rodriguez Стр. 26 – Фотограф: Сергей Волков Стр. 50 – Фотограф: Сергей Волков Стр. 113 – Фотограф: Eduardo Soteras Jalil Стр. 156 – Фотограф: Nursila Dewi Стр. 202 – Фотограф: David Spitz Стр. 208 – Фотограф: David Spitz © Всемирный банк Стр. 49 – Фотограф Scott Wallace Стр. 61 – Фотограф: Sarah Farhat Стр. 64 – Фотограф: Andy Trambly Стр. 100 – Фотограф: Tom Perry Стр. 118/119 – Фотограф: Mohammad Al-Arief Стр. 182 – Фотограф: Khasar Sandag © Photoshare Стр. 46 – Фотограф: Kassia Meinholdt Стр. 53 – Фотограф: Sanghamitra Sarkar Стр. 81 – David Alexander / Центр коммуникационных программ Джонса Хопкинса Стр. 90 – Фотограф: Syed Ziaul Habib Roobon Стр. 126 – Фотограф: Sumon Yusuf Стр. 142 – Samy Rakotoniaina / MSH Стр. 196 – Фотограф: Meagan Harrison Другие источники Стр. 15 – © Всемирная организация здравоохранения Стр. 17 – © Bloomberg Philanthropies Стр. 19 – © Секретариат Конвенции РКБТ ВОЗ Стр. 30 – © Секретариат Конвенции РКБТ ВОЗ Стр. 34 – © Fondo Solidario para la Salud - FOSALUD, Сальвадор Стр. 55 – © Фотограф: Husain Akbar Стр. 57 – © Фотограф: Husain Akbar Стр. 63 – © Министерство здравоохранения Бразилии Стр. 74 – © Подразделение по неинфекционным заболеваниям Федерального министерства здравоохранения Судана Стр. 75 – © Национальный институт научных исследований и разработок в области здравоохранения, Индонезия Стр. 79 – © Фотограф: Robert Totanes Стр. 80 – © Сианьская комиссия по здравоохранению, Китай Стр. 81 – © Г-н Omar Badjie, Министерство здравоохранения Гамбии Стр. 88 – © Министерство здравоохранения и благополучия семьи, Индия Стр. 88 – © Д-р Oumar Ba, Министерство здравоохранения и социальной защиты, Сенегал Стр. 89 – © Национальный центр по борьбе против табака, Республика Корея Стр. 89 – © Министерство здравоохранения Эквадора Стр. 94 – © Комитет по здравоохранению и социальным вопросам парламента Грузии Стр. 95 – © Министерство здравоохранения Уругвая Стр. 99 – © Young Guns Media, Мьянма Стр. 99 – © Страновой офис ВОЗ в Китае Стр. 104 – © Г-жа Rosalie Likibi-Boho, Министерство здравоохранения Республики Конго Стр. 104 – © Ada Moadsiri, Всемирная организация здравоохранения Стр. 105 – © Stabroek News, Гайана Стр. 116 – © Министерство здравоохранения Ирландии Стр. 117 – © Г-жа Hanitra Ratsirison, Министерство здравоохранения Мадагаскара Доклад ВОЗ о глобальной табачной эпидемии, 2019 год подготовлен при финансовом содействии Благотворительного фонда Bloomberg Philanthropies 20 Avenue Appia • CH-1211 Geneva 27 • Швейцария www.who.int/tobacco