Introduction: It was adopted by the World Health

Tobacco use is the single greatest preventable cause of death in the world. Globally, tobacco kills nearly 6 million people a year and is a risk factor for six of the eight leading causes of death (, 2008). Moreover, global tobacco use caused more than US$1 trillion in health-care costs and lost productivity annually (, 2018). In response to this epidemic, the Framework for Tobacco control (FCTC) was formed, a supranational treaty negotiated under the WHO aimed at reducing the supply and demand of tobacco in order to “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke”(, 2003). It was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005. It had been signed by 168 countries and is legally binding in 180 ratifying countries which represents 90% of the world’s population (World Health Organization, 2017). The FCTC has provided a framework for tobacco control measures to be implemented and has outlined targets that the parties should strive to achieve. This essay will examine the effectiveness of these initiatives and explore the barriers that have impeded its success. 

How effective has the FCTC been? 
The FCTC has seen much progress since its introduction in 2003. 68% of parties have adopted the provisions; the proportion of parties reporting development and implementation of multisectoral national strategies, plans, and programmes increased from 49% in 2010, to 59% in 2012. More than 75% of parties strengthened existing legislation or adopted new tobacco control policies after ratification of the treaty (, 2013). 
In 2008 the WHO introduced the MPOWER package of evidence-based tobacco control measures alongside its articles to assist countries with implementing FCTC obligations. Figure 1 shows the proportion of countries that have implemented MPOWER and the colours reflect the degree to which they have been adopted, from minimal policies through to complete policies. 

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The data shows definite progress with all but one MPOWER measure being utilised in some form by over 50% of the signatories. Particular success has been shown with cessation programmes and taxation with over 80% of countries operating policies. Figure 2 illustrates how currently around 4.7 billion people (63% of the world’s population) are covered by at least one comprehensive tobacco control measure, which has quadrupled since 2007 when only 1 billion people (15% of the world’s population) were covered. Although there are still many countries who have not implemented policies or some only at a low level, MPOWER has been gaining momentum since its introduction and has progressively been adopted by more nations.  

The FCTC policies through MPOWER have been proven to have had an effect on smoking as shown through the research of Gravely et. al. They examined the correlation between key demand-reduction measures of the FCTC and change in smoking prevalence in 126 countries between 2005 and 2015. Their findings showed that the mean smoking prevalence for the 126 countries studied was 24.73% in 2005 and fell to 22.18% in 2015, a decrease of 2.5%. 

The study also found that on average, each additional measure of MPOWER implemented at the highest level was associated with 7.1% fewer smokers in 2015, relative to the number of smokers in 2005. (Gravely et al., 2017). This empirical evidence shows the positive impact that these policies can have on smoking reduction and showing that the more they are implemented, the more smoking rates are likely to decrease.

Turkey is the only country within the FCTC that fully implements all six of the MPOWER measures at the highest level. It exemplifies the effectiveness that the FCTC has had in tobacco control. The smoking prevalence significantly decreased among adults from 31.2% (16.0 million) in 2008 to 27.1% (14.8 million) in 2012 (, 2013). There have also been many other successes such as significant reduction in second hand smoke exposure after implementation of the national smoke-free law in 2009. Figure 3 which shows participants exposure to secondhand smoke in various places (in the past 30 days) and in just four years there have been some dramatic changes. In restaurants exposure went from 55.9% to 12.9% from 2008 to 2012 and homes also saw a large decrease. Considering that second-hand smoke caused 603,000 global deaths in 2004 and millions of other smoking related diseases such as respiratory infections (Öberg et al., 2011), the  FCTC has shown success at reducing this burden with countries like Turkey and 55 countries operating smoke free policies at the highest level (according to figure 1). Turkey also increased cigarette increased tax rates raised the price of cigarettes by 195% between 2005 and 2011. During this time period, cigarette tax revenues increased by 124%, while cigarette sales decreased by 15.5% (, 2012). Figure 4 illustrates how as the price of cigarettes increased, sales of cigarettes however tax revenue increased. 

Uruguay is another country where the FCTC has seemingly been very effective. In 2005, Uruguay initiated a series of comprehensive anti-smoking measures including actions such as the banning of tobacco advertising, the banning of smoking in all enclosed public spaces, tax increases, and legislation requiring that pictograms with health warnings cover 80% of both the front and back of every cigarette pack. A population-based trend analysis found that from 2005 to 2011, the prevalence of current tobacco use in Uruguay decreased annually by an estimated 3·3% and adolescent smoking prevalence by 8·0% per year (Abascal et al., 2012). The study found that the control campaign had been directly associated “with a substantial, unprecedented decrease in tobacco use”. 

Another success of the FCTC is how via its terms and the institutions and processes it has generated, it has brought tobacco control to the international agenda. It has incorporated NGOs with wide and varied expertise in all areas of tobacco control enabling them to collaborate and attend FCTC negotiating meetings (Lencucha et al., 2010). 

However, although the progress of WHO FCTC ratification has been remarkable with 179 countries and the European Union, covering nearly 90% of the world’s population and its effectiveness in certain individual countries, implementation of the treaty has been slow, lacking in developing nations and has not always been at the highest level, or at all. There are still many countries where implementation has fallen short of the standards set by WHO FCTC.

Firstly, looking specifically at cigarette taxation, which has been proven to be a very effective and cost-effective way of reducing tobacco use (Bader et. al., 2011), it is clear this is an area where the FCTC has not been particularly effective. Only one in 10 of the world’s people live in the 33 countries that levy taxes of more than 75% of the cigarette retail price, making it the least- implemented MPOWER measure (, 2015). The overriding majority of these countries are also high income countries. Given that nearly nearly 80% of the world’s more than 1 billion smokers live in low- and middle-income countries (World Health Organization, 2017), the FCTC has been particularly ineffective in implementing this policy. Figure 5, taken from a WHO report on ‘Raising taxes on tobacco’,  separates the various tax structures and shows the number of countries that have implemented them and separating low, middle and high income countries. It is clear that low-income countries are particularly underrepresented with only 18 imposing a uniform excise tax and no low-income country having a tax component automatically adjusted to inflation. The same report found that between 2010 and 2014, the general trend for low-income countries was for cigarettes to become more affordable over time due to taxation not exceeding economic growth and inflation. Figure 6  shows how in high-income and middle-income groups there was a general uptrend in the % of GDP per capita used to buy 100 packs, however there was a definite decrease for low-income countries between 2010 and 2014. Among the countries that smoking has become more affordable were China, India, Indonesia and Vietnam and those three countries alone account for almost 50% of the proportion of smokers in the world (, 2008). 

A study that looked at smoking prevalence and cigarette consumption in 187 Countries from 1980 to 2012 found interesting results. Although there has been a general downtrend in smoking prevalence (see figure 7), the decreasing prevalence amongst men has slowed since 2006 in  developing countries and started to increase after 2009. Looking at the annualised rate of change shows how in 2012 the global percentage change in smoking prevalence was positive for males, the first time since 1985 (Ng et al., 2014). Looking at worldwide regions it is evident from figure 8 that only the some of the wealthiest nations in the world, Australia, North America and Western Europe have seen a significant decline in cigarette consumption. China has seen an enormous increase in cigarette consumption, almost doubling between 1998 and 2016 (Gilmore et al., 2015). This data shows how although the FCTC has shown success in individual countries (mainly of high income status), its effect on worldwide prevalence and consumption particularly in developing countries has been largely ineffective. 


The barriers facing the FCTC
There are a variety of barriers that have impeded the effectiveness of the FCTC since its implementation. 
Tobacco company interference thwarts effective action of the FCTC as they continuously adapt their tactics to circumvent new laws and regulations controlling its activities with the aim of safeguarding their profits.
Tobacco companies have the ability to put significant pressure on governments to restrict their implementation of FCTC guidelines. This undermines article 5.3 of the FCTC, to insulate public health policymaking from industry interference. Spain is an example of a country where the tobacco industry has intervened and prevented their policies from fully aligning with the demands of the FCTC. Research shows that tobacco companies here, specifically Phillip Morris, sought to reduce the impact of smoking restrictions in hospitality venues by promoting separate seating for smokers and ineffective ventilation technologies, supporting an unenforceable voluntary agreement between the Madrid local government and the hospitality industry, influencing ventilation standards setting and manipulating Spanish media (Muggli et al., 2009). Tobacco companies now use Spain as a counter-model of tobacco control to spread a failed approach on an international level as a way to influence other countries to enforce weaker legislation (Schneider N. at al., 2011). 
The tobacco companies are also aggressively using the threat of infringement of trade agreements as a deterrent or negotiating point, which provides the industry with ammunition to obstruct control policies in both developed and developing countries and at every level (eg, decrease in the size of warning labels, lack of implementation) (Shaffer, 2005). An example of these actions is in Kenya where British American Tobacco have succeeded in delaying regulations to restrict the promotion and sale of cigarettes for 15 years, fighting through every level of the legal system on the basis that the restrictions were “inconsistent with and in contravention of the constitution”(Boseley, 2017). 

Tobacco companies find ways to undermine laws and take advantage of loopholes. For example, in Mauritius, the tobacco industry used delay tactics to bypass a new smoking restriction by taking advantage of a loophole in the law that did not specify a supply date of the tobacco products that complied with the new law. As a result, they stockpiled tobacco products manufactured before the the law was enforced, enabling them to supply non-compliant tobacco products several months after the law had entered into force (Tumwine, 2011). Not only does this stand in the way of providing safer products to countries but it also undermines the authority of governments and the FCTC. 

Tobacco companies have also found ways to undermine tobacco tax policies to prevent relative price rises in cheaper tobacco products. In the UK, from 2012 (after adjusting for inflation) the average real prices for the cheapest factory made and roll-your-own products remained steady. This was due to the tobacco industry absorbing the tax increases on the cheapest brands to offset increases in tax. This tactic enables the cheapest range to remain cheap which targets new smokers and the poorest of society and undermines the governments attempt to make smoking unaffordable (Hiscock et al., 2017). 

Another issue that faces the FCTC is the fact that the tobacco industry is of substantial economic importance and millions of people worldwide rely on the industry as a source of income leading to political difficult. Research in Macedonia shows how although it has ratified the FCTC and implemented policies, the government still drives the tobacco industry by showing support and subsidising tobacco farming. The country has an unemployment rate of over 31% and tobacco represents one-quarter of the agricultural export of the country. By keeping the tobacco industry thriving it provides over 40,000 more households with a source of income and prevents loss of export (Lazarevik, Spasovski and Donev, 2012).

This conflict between commercial, politically vested interests and public health is also seen in China. It is a state run monopoly which produces 43% of the worlds total tobacco accounting for 7.26% of the government revenue and there are approximately 20 million farmers who are engaging in the production of tobacco leaf, with many more people relying on the industry (Li et al., 2012),(Hu et al., 2013). Although the health risks and benefits of smoking restrictions are well known, government leaders view the continued growth of the tobacco industry as integral to the political, economic and social wellbeing of the country clashing with public-health policies. This has led to ‘half-hearted efforts and miniscule resources’ devoted to FCTC implementation (Hu, Lee and Mao, 2013). China exemplifies how the prominence of the industry and how it is so deeply embedded culturally, socially and economically prevents effective FCTC implementation. 

The illicit tobacco trade is another major barrier for the FCTC. Tobacco smuggling removes the disincentive to smoke as a result of tax increases and takes away from potential tax revenue thus undermining one of the most cost efficient methods of tobacco control. A recent report found that illicit cigarettes accounted for 14.3% of all cigarettes consumed in the UK in 2016 and accounted for £1.84bn in lost tax (, 2016). The FCTC acknowledges the threat that it has on public health and the treaty aims to eliminate all forms of illicit trade in tobacco products. However, attempts to eliminate or even reduce the illicit trade from the market is made difficult for countries by tobacco company interference. Governments have, in some cases, developed ‘partnerships’ with tobacco companies who pledge to assist in reducing illicit trade but this collaboration intertwines the relationship between the two parties more and adds extra complexity for tobacco control implementation (Malone and Bialous, 2014). Research also shows that the tobacco companies commission surveys using methodology and validity that remains ‘uncertain’, plant ‘misleading stories’ and ‘misquote government data’ (Rowell A. et al., 2014) to bolster its arguments against tax increases and other tobacco control measures. The industry has even been accused of fuelling the illicit trade in cigarette smuggling to strengthen its claims against high taxation (Action on Smoking and Health, 2015). 

Enacting tobacco restrictions is a significant undertaking for governments and to support the development and implementation of comprehensive tobacco control programmes, countries need an in-place effective, supportive infrastructure. Low-income countries often lack the resources and prioritisation on tobacco control needed to fully implement the provisions of the FCTC. In India, a report revealed that it lacks the ability to provide cessation treatment for tobacco users who wanted to quit. There was also a lack of education infrastructure and only half of adults are aware that smoking causes stroke and less than two-thirds understand the connection between smoking and heart disease (Schwartz R. et al., 2011). Research in Gahna found that ‘limited resources’ and ‘lack of capacity to effectively deal with the … epidemic’ where some of the main barriers facing implementation of the FCTC (Owusu-Dabo et al., 2010). Per-capita expenditure on tobacco control ranges considerably between high and low income countries. High income countries on average spend US$1·80 per capita per year compared to US$0·005 in middle-income countries and to US$0·001 in low-income countries (Callard, 2010).

Lack of governmental prioritisation for the FCTC and tobacco control in another barrier impeding effective implementation. There is a lack of awareness among non-health government ministries  as well as development partners and a WHO report on FCTC integration into UN and National Development Planning Instruments found that many countries failed to mention the FCTC or even tobacco control (, 2014). Figure 9 shows how out of the 48 countries studies, 30 failed to mention tobacco and only 4 included specific WHO FCTC inclusion in their UNDP’s. 

The FCTC is a remarkable feat of worldwide collaboration and has had many positive effects. However, implementation has been slow, sub-standard and lacking in many countries, and it has failed to tackle the growing tobacco epidemic in low income countries. 
Tobacco industry interference with governments’ efforts to implement tobacco control policies is one of the greatest challenges faced by the FCTC. While there are countries that actively have resisted tobacco industry pressure and achieved effective tobacco control, in other countries, despite a legal obligation to implement the FCTC, progress is slow and a growing epidemic that could be prevented continues to escalate. In order for positive progression of the FCTC to be achieved, particularly targeting low income countries, tobacco control needs to be prioritised by all parts of government and woven into the fabric of international relations, especially international trade.