Making progress in the fight against tobacco
Authors: None The Lancet Public Health
Journal: The Lancet Public Health (2019)

Killing more than 8 million people a year, the tobacco epidemic remains a serious and global public health threat. The adoption of the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003 was a major step forward in international efforts to control the tobacco epidemic, and reduced smoking harms in countries that implemented its suite of evidence-based policies: MPOWER (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). According to the 2019 WHO report on the global tobacco epidemic, about 5 billion people, 65% of the world population, are now covered by one of these measures. Nevertheless, at about 20%, smoking prevalence remains high globally. Smoking rates are highly heterogenous among countries—ranging from 8·7% in Sweden to 27% in Greece and Bulgaria in Europe, for example. The latest Global Burden of Disease analyses published in this issue of The Lancet Public Health highlight that in Italy and Denmark, in particular, smoking remains a leading cause of healthy life-years lost. In this issue, three research Articles help us to take stock and evaluate tobacco control measures that use legislative bans, taxation, or individual behavioural support to quit smoking. The first study, by Timor Faber and colleagues, examines the effectiveness of legislation introduced in England in 2015, which banned smoking in private vehicles with children onboard. The authors find that the introduction of smoke-free vehicle regulation was not associated with a significant change in self-reported prevalence of respiratory conditions or exposure to tobacco smoke in children. One in 20 children in England still reported exposure to tobacco smoke in a car and one in three of those tested had detectable concentrations of salivary cotinine. The seeming lack of effect of the smoke-free vehicle legislation noted in this first national evaluation might be due to a lack of active enforcement by the police service and lack of a strong media information campaign alongside the legislative changes, and reinforces the need for more effective approaches to protecting children. In the second paper, Anna Wilkinson and colleagues examine smoking prevalence data from Australia to determine the longer-term effect of planned, year-on-year tobacco tax increases. Australia, which has some of the strongest tobacco control policies in the world, uniquely introduced a one-off large tobacco tax increase of 25% in 2010, followed by a series of smaller, annual increases of 12·5% over 4 years from 2013. Although both tax regimens saw declines in overall smoking prevalence, under the one-off 25% tax, reductions were mostly due to factory-made cigarettes, while prevalence of smoking roll-your-own tobacco (RYO) products increased, mostly in low socioeconomic status (SES) groups. This suggests that smokers were switching to cheaper tobacco products in response to the 25% tax and that tobacco companies were able to reduce the tax's impact. Under the annual 12·5% tax increases however, RYO prevalence decreased and stayed down among low SES people. Taxing tobacco products can clearly be effective in lowering smoking prevalence, especially where it limits tobacco companies’ ability to adjust to the tax increases. In the third paper, Loren Kock and colleagues ask whether behavioural stop smoking interventions can be effectively tailored toward individuals from low socioeconomic backgrounds—a group with higher smoking prevalence on average and lower successful quit rates. In their systematic review and meta-analysis, they find that although all patients receiving an intervention had much higher odds of successfully quitting than control participants, tailored interventions were not more effective at helping patients from low SES backgrounds to quit smoking, suggesting that more research is needed to help specific groups. The research published in this issue shows that reducing the burden of tobacco smoking is possible using MPOWER evidence-based policies, but also suggests that partial implementation might undermine effectiveness and fail to protect the most vulnerable—such as children. The disproportionate burden of smoking among socioeconomically disadvantaged people is a further challenge that requires novel multifaceted approaches that embed the wider context of socioeconomically disadvantaged smokers. Italy's health performance, 1990–2017: findings from the Global Burden of Disease Study 2017Italy provides an interesting example of the results that can be achieved by a mix of relatively healthy lifestyles and a universal health system. Two main issues require attention, population ageing and gradual decrease of public health financing, which both pose several challenges to the future of Italy's health status. Our findings should be useful to Italy's policy makers and health system experts elsewhere. Full-Text PDF Open AccessInvestigating the effect of England's smoke-free private vehicle regulation on changes in tobacco smoke exposure and respiratory disease in children: a quasi-experimental studyWe found no demonstrable association between the implementation of England's smoke-free private vehicle regulation and changes in children's self-reported tobacco smoke exposure or respiratory health. There is an urgent need to develop more effective approaches to protect children from tobacco smoke in various places, including in private vehicles. Full-Text PDF Open AccessLife expectancy and disease burden in the Nordic countries: results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2017Risk factor differences might drive differences in life expectancy and disease burden that merit attention also in high-income settings such as the Nordic countries. Special attention should be given to the high disease burden in Greenland. Full-Text PDF Open AccessSmoking prevalence following tobacco tax increases in Australia between 2001 and 2017: an interrupted time-series analysisLarge tax increases are effective in reducing smoking prevalence, both as a single increase without forewarning and as a pre-announced series of increases. However, taxes on tobacco are best structured to apply equally to FMC and RYO products. Tobacco control policies should prohibit price marketing that otherwise erodes the full impact of such tax increases. Full-Text PDF Open AccessIndividual-level behavioural smoking cessation interventions tailored for disadvantaged socioeconomic position: a systematic review and meta-regressionWe found evidence that individual-level interventions can assist disadvantaged smokers with quitting, but there were no large moderating effects of tailoring for disadvantaged smokers. Improvements in tailored intervention development might be necessary to achieve equity-positive smoking cessation outcomes. Full-Text PDF Open Access