tobacco use dissertation

Salford Public Health

A blog from the Public Health team at the University of Salford

My Masters Dissertation on tobacco use in new migrant communities By Nisha Kassam

This is my first time blogging and I hope that this piece helps others in their journeys when starting their dissertation projects. At first, I had no understanding of how big a task writing a dissertation was and how much it would consume my life! From the research methods module, I knew that I wanted to look into my own research area and I wanted to build upon a piece of work that I had worked on from start to finish, so my dissertation journey started from picking a topic area of interest and it ended with a report being presented to Manchester City Council. A couple of weeks after submitting the report to the council, I got an email from the council informing that my work will be used in an upcoming Council guideline. I will be referenced in their work, which I still to this day can’t believe is happening!

From the start of the dissertation module, I buddied with up a course colleague, David Gilbert, and we set out a task schedule and went over all the tasks that we needed to complete for the dissertation. We had the same supervisor so that made it easier for us to bounce ideas off each other and work together, it was also great having someone who was working at the same pace as me. We had a lot of late nights in the library working on our individual projects, with delirium usually happening around 2 am in the morning. We would find ourselves arguing over who our supervisor’s favorite student was and shouting ‘noooooo more!!’ at our computer screens after receiving our feedback, which meant more work for us to do. (Helpful hint: if working in the library take snacks—we always got the munchies around midnight and that helped to fuel us on through the night and also there are food options that can be delivered to the library!!!.)

Onto the practical side of things, it was important for me to collaborate with one of the city councils, as they would help in providing resources and would also help in refining the topic area being researched. I approached Manchester City Council during the research proposal stage of my work and they offered to assist me in the dissertation project. My initial topic area of interest was shisha/waterpipe smoking in Manchester, however, the council had already completed a lot of work on waterpipe/shisha smoking and asked me to look at a new area that was under-researched. So my dissertation project changed direction, looking at tobacco use and smoking in new migrant communities. The council provided me with the resources to complete the research project, insofar as access to migrant communities that could take part in focus groups.

I jumped into the research side of things and started conducting focus groups with different migrant communities. I had given myself a month to collect data and then planned to analyse the data, however, the council asked for more out of the project, they wanted to look at the project from different points of view, so that they could have a complete overview of tobacco use in Manchester. Interviews with primary care professionals were added to the project. I approached primary care professionals that the council recommended, as well as primary care professionals I knew through my work as an Operating Department Practitioner. I used all the contacts available to me in order to make my research project successful. However, adding another aspect to the dissertation project was the greatest challenge as it meant that the project changed from being one dimensional to being a triangulated research project. This meant analysing data from different perspectives and also meant further ethical approval was needed for the interviews, adding more layers to an already complex project.

In terms of findings from the research, I found that alternative tobacco products were popular in new migrant communities, many migrants were using different tobacco products including shisha/waterpipes, and heated tobacco units. These products were becoming more popular due to the flavours on offer and also their price points. However, the research indicated that cigarettes were still the most prominent form of tobacco being used within new migrant communities, although migrants were finding ways to get cheaper cigarettes, thus were importing cigarettes from their home countries or were buying cheaper/counterfeit cigarettes from certain supermarkets or corner shops.

 There were no services specifically for new migrants, and a lack of data collection on new migrants makes it difficult to track their needs. Gaps in the research were presented clearly and I also included recommendations and conclusions in the report, which the council could implement in the future.

Photo by  Ander Burdain  on  Unsplash

So I still can’t believe that this was the outcome of my work, to be referenced in an important guideline for the council that I was collaborating with. Getting the email to say that my work was being used was completely unexpected, but this meant that all the late nights and library visits were totally worth it…

The one thing that I would recommend to future students is to work systematically, plan everything from data collection to data analysis, timetable your plans and make lists. (Lists are super important in detailing everyday details, the guys on my course used to make fun of my list making, but they do work!) 

As cliché as it sounds, doing a dissertation is a real journey, and it presents a lot of challenges along the way, but the key is perseverance and hard work.  I enjoyed every aspect of it, from the data collection to the analysis to write up. Even if it meant sleepless nights and no social life for a few months, it is totally worth it! Even now, as I’m writing this, I am now thinking I want to do more and work on other research areas.

(As a side note, I also want to publicly thank the lecturers on this course, as without them none what I have achieved would have been possible without them and their input.)

Fralin Biomedical Research Institute’s new lab will take aim at tobacco use, cancer rates, and informing policy

Roberta Freitas-Lemos wants to provide policymakers with research-informed strategies to influence health behavior and lower cancer rates related to tobacco, one of the world’s biggest public health threats.

Leigh Anne Kelley

17 Apr 2024

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As a new faculty research team leader at the Fralin Biomedical Research Institute at VTC, Assistant Professor Roberta Freitas-Lemos seeks to improve health equity in controlling and preventing cancer, particularly as it relates to tobacco use. Photo by Clayton Metz for Virginia Tech.

Open-water swimming requires athletes to take into account a wide number of variables.  Roberta Freitas-Lemos  said when she’s in the ocean, temperature fluctuations, murky conditions, and the motion of the waves make it a challenging sport, both physically and mentally.

Complexity also characterizes Freitas-Lemos’ research at the  Fralin Biomedical Research Institute at VTC , where she works at the intersection of tobacco use, health equity, and cancer. How do market and regulatory changes affect health behavior? How do variables such as pricing and product mix influence what substances, or therapies, people turn to? And how do those choices moderate or amplify health disparities?

On April 1, Freitas-Lemos began her new position as a group leader and assistant professor with the Fralin Biomedical Research Institute and is establishing her independent research program within its Center for Health Behaviors Research and the Cancer Research Center in Roanoke. She is also a tenure-track assistant professor in the Department of Psychology in the  College of Science .

Her focus is tobacco, the leading cause of preventable death and disease in the U.S. and the cause of more than 8 million deaths annually worldwide. She is swimming in the deep end of what the World Health Organization calls one of the world’s greatest public health threats.

Her research program uses behavioral economics and tools such as the Experimental Tobacco Marketplace to provide insight into policies and products that can help reduce smoking and improve lives through large-scale intervention.

“I want to be able to use findings from the marketplace to inform policy,” Freitas-Lemos said. “That’s the important gap that we have right now — getting scientifically grounded data to inform how to reduce cancer rates.”

Her work is supported by a five-year, $680,000  career-development award  from the National Cancer Institute of the National Institutes of Health.

Blazing trails in Brazil

Before joining the Fralin Biomedical Research Institute, Freitas-Lemos spent 15 years in Brazil working on various government programs to improve people’s lives using behavioral principles.

Her early experience was with at-risk adolescents, communities dealing with substance use, families struggling with poverty, and Indigenous populations and traditional communities facing challenges in health care information and access.

At one point she was working for the state government of Acre, in the northwest part of the country bordering Peru and Bolivia. “I went to live in the Amazon. It was a very simple life. I actually enjoyed it a lot,” she said. “It was there I saw how one action from the government can impact so many people.”

She became a consultant and policy analyst for the federal government’s Ministry of Health, Ministry of Human Rights, and Ministry of Social Development, turning her attention to such topics as the Venezuelan migration crisis, child protection, addiction, gender equity, and the Zika virus. 

“All these emerging topics needed fast solutions. Tobacco was a problem across all programs, and all populations,” she said. “I saw the harmful effects of tobacco, and how difficult it was for scientists to inform decision-making.”

She earned a doctorate in behavioral sciences from the University of Brasília, where she was exposed to the work of Professor Warren Bickel, director of the Fralin Biomedical Research Institute’s  Addiction Recovery Research Center  and  Center for Health Behaviors Research .

Bickel and Rudy E. Vuchinich were co-editors of “Reframing Health Behavior Change with Behavioral Economics,” a book that gave Freitas-Lemos a new perspective on how science-informed public policy could influence health and well-being. “I read their chapter and thought it was brilliant,” she said. “I thought I should train under Bickel and understand what could be done with behavioral economics.”

She joined the Fralin Biomedical Research Institute as a postdoctoral associate in 2019.

Tobacco and cancer

A primary focus of her approach has been the Experimental Tobacco Marketplace, which Bickel developed to study the effect of tax and regulatory policy on nicotine purchases.

In the marketplace, study participants use an online account to purchase tobacco and replacement therapy products based on their reported use. Researchers adjust the product mix and pricing on an Amazon-like interface to predict their effects on purchase behavior.

“I want not only to examine policies proposed by government, but create novel and unexplored policies and integrate findings with population-based modeling," Freitas-Lemos said. "That will allow me to project cancer rates and conduct the cost-benefit analysis needed to quantifiably understand the trade-offs related to implementation, disparities, and long-term health.

“From my work with policymakers in Brazil, I know that they need very specific numbers," she said. "Will policies mean that people are going to quit tobacco? Or transition to something else? How many people will be impacted, and how will different interventions impact government spending?”

Freitas-Lemos has conducted research and co-authored a number of studies using the marketplace, including the effect of  e-cigarette restrictions  and  menthol and filter ventilation bans  on illegal purchases as well as the socioeconomic disparities of different tobacco policies. She also has more than three dozen published articles related to behavioral psychology, addiction, episodic future thinking, and social disparities, some informed by her work in Brazil.

In her new role she looks forward to developing methods to investigate health disparities, developing novel polices that are easy to implement, and improving treatment by enhancing the appeal of safer products and testing different interventions for people who use tobacco.

And if her schedule allows, more training may be in the offing. Freitas-Lemos is still in touch with her swimming coach in Brazil, and she has her eye on a February 2025 open-water challenge in Rio.

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UK set to ban tobacco sales for a ‘smoke-free’ generation. Will it work?

The UK’s smoking ban aims to phase out sales of tobacco, which is one of the main causes of cancer deaths in Britain.

Britain is set to impose tough measures to stub out smoking, which has emerged as one of the biggest causes of cancer deaths in the country.

Parliament approved the government’s “historic” plans to create a “smoke-free” generation on Tuesday in a bid to reduce the number of people dying from smoking-related diseases, a big burden on the country’s publicly funded National Health Service (NHS).

Keep reading

Australia to ban single-use vape imports from 2024, ‘poison in every puff’: each cigarette in canada to carry warning, what’s being done to repair damage done by smoking.

MPs voted 383-67 to give the Tobacco and Vapes Bill a second reading, overcoming vocal opposition from a section of the ruling Conservative Party, which opposes state interference in people’s lives. It now needs approval from the House of Lords to come into effect. No party in the 790-member Lords has an overall majority, but the Conservatives outweigh Labour 278-173.

“Parliament has now begun the process of consigning smoking to the ash heap of history,” Deborah Arnott, chief executive of the pressure group Action on Smoking and Health, told Al Jazeera.

“The passage of the bill should be expedited to ensure it is on the statute book before the general election. The public, who overwhelmingly support the legislation, expect nothing less,” she said.

What does the UK’s ban cover?

Rather than criminalising the habit, the bill aims to ensure people turning 15 this year and those who are younger will never be able to legally buy tobacco.

Currently, it is illegal to sell cigarettes to anyone under the age of 18. The government intends to bar sales to anyone born after January 1, 2009. Under the legislation, beginning in 2027, the legal age limit would increase by one year every year until it is illegal for the entire population.

If all goes according to plan, the government envisages that smoking among young people would be eradicated by 2040.

Shops in England and Wales caught selling cigarettes and vapes to underage people would face on-the-spot fines of 100 pounds ($125). Courts may already impose fines of 2,500 pounds ($3,118).

“We do expect over time, smoking to die out almost completely,” said Chris Whitty, chief medical officer for England, speaking on BBC Radio 4.

What’s behind the UK’s new rules?

Smoking is the United Kingdom’s biggest preventable killer.

About 13 percent of the adult population – 6.4 million people – were smokers in the UK in 2022, the Office for National Statistics estimated.

That is much lower than other European countries such as Italy, Germany and France, where 18 to 23 percent of adults smoke, according to figures from the Organisation for Economic Co-operation and Development (OECD).

Official figures show the habit leads to 64,000 deaths in England per year, causing about one in four deaths from cancer .

Medical and healthcare experts and charities say the toll is higher, estimating that smoking causes 80,000 deaths every year.

With the new ban, the UK government hopes to prevent more than 470,000 cases of heart disease, stroke, lung cancer and other diseases by the end of the century.

The legislation also seeks to clamp down on young people vaping by restricting flavours and packaging to make it less appealing to children. The jury is still out on vaping with the NHS judging it as “not risk-free”.

How is the ban viewed?

Pollsters found about two-thirds of people in the UK back a phased smoking ban.

Health Secretary Victoria Atkins told the House of Commons there is “no liberty in addiction”.

“Nicotine robs people of their freedom to choose. The vast majority of smokers start when they are young, and three-quarters say that if they could turn back the clock, they would not have started,” she said.

But libertarian-leaning MPs on the right of the ruling Conservatives, including former Prime Minister Liz Truss, have branded the move an attack on personal freedoms. During the parliamentary debate, Truss said it was a piece of “virtue-signalling”.

Business Secretary Kemi Badenoch said she was not a smoker and agreed with Prime Minister Rishi Sunak’s intentions but said she opposed the bill because she was concerned about its impact on people’s rights and difficulty in enforcing the policy.

“We should not treat legally competent adults differently in this way where people born a day apart will have permanently different rights,” she said on the social media platform X.

I’m not a smoker and think it is an unpleasant habit, costly for both the individual and society. The PM's intentions with this Bill are honest and mark him out as a leader who doesn't duck the thorny issues. I agree with his policy intentions BUT….(1/4) — Kemi Badenoch (@KemiBadenoch) April 16, 2024

The legislation is one of Sunak’s flagship policies before the general election  this year, which opinion polls suggest the opposition Labour Party would win.

“It’s world-leading in terms of reducing harms caused by tobacco and may lead to other countries following suit with similar measures,” said Dr Allen Gallagher, a research fellow in the Tobacco Control Research Group at the University of Bath.

Other approaches tried so far include price and tax measures, regulating the content of tobacco products, packaging and labelling measures, and advertising restrictions.

“This is the first test of a generational phasing-out of tobacco,” Gallagher told Al Jazeera.

“Time will tell if it’s enough.”

Have other countries imposed similar anti-smoking bans?

According to the World Health Organization (WHO), tobacco kills more than eight million people each year, including an estimated 1.3 million non-smokers who are exposed to second-hand smoke.

The proposed ban is thought to have been inspired by a similar plan in New Zealand, introduced under former Prime Minister Jacinda Ardern but scrapped this year by the new coalition government before it could be enforced. By stopping a generation from taking up smoking, the country of five million hoped to avoid about 5,000 preventable deaths a year.

In May, Portugal presented legislation to restrict tobacco sales and extend a ban on smoking to outdoor areas, including covered terraces. The country hopes to raise a tobacco-free generation by 2040. According to government estimates, about 13,500 deaths in 2019 were due to tobacco use in Portugal, which has a population of about 10 million.

Last year, Mexico brought one of the world’s most stringent smoking laws into force, implementing a total ban in public places, including hotels, beaches and parks, and stopping advertising. The WHO’s Pan American Health Organisation (PAWHO) estimated that smoking causes more than 10 percent of deaths in the country of 128 million, amounting to about 63,000 per year.

Also last year, Canada became the first country to introduce printed health warnings on individual cigarettes. Messages include “poison in every puff” and “cigarettes cause impotence”. Tobacco use remains the leading preventable cause of illness and premature death in the country of 39 million, killing approximately 48,000 people each year.

Since 2002, India has had a ban on smoking in public spaces although organisations can create specific smoking zones.

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The UK’s smoking ban is government meddling at its worst and most pointless

Tobacco is already on its way out. The state should not deny adults the right to make personal decisions for themselves

J ust because Liz Truss and Boris Johnson – both opposed to the government’s proposed new smoking ban – hold a belief does not make it wrong. Smoking is unpleasant, but in this week’s parliamentary debate, the word nicotine could have been replaced by cannabis, alcohol, ultra-processed foods, base jumping or mobile phones for children. All have their dangers. But in each case those in favour of restrictions rely on the same argument; if something produces a burden on the state it should be banned. Personal liberty can go hang.

Rishi Sunak’s anti-smoking bill carried the same smudgy fingerprints as his bill on Rwanda. It suggested a late-night Downing Street cabal desperate for somethingeye-catching to inject into the election campaign. It does not ban anyone from smoking, despite appearances. It bans shops from selling cigarettes to an ever-expanding age cohort, currently anyone under 18, with the legal cutoff increasing by one year each year. People born in or after 2009, in other words, will never be able to legally buy a cigarette in Britain. The bill’s target is shopkeepers, charged with juggling the ID cards of hordes of adult purchasers and presumably proxy buyers. The smugglers must be cheering.

So far Britain’s efforts to curb smoking – built on the nudge principle – have been remarkably effective. This has been achieved, as many economists would advise, by working on demand rather than supply. Cigarette use has fallen over the past half-century from about 45% of the population in 1974 to about 12% today and it continues to fall. The method has been to stop smoking indoors, in public enclosed spaces and around children. Advertising has been banned, vending machines abolished and children cannot buy cigarettes. The introduction of vaping, though controversial when it’s young people doing it, is understood to have helped accelerate the fall in smoking, as per the drug policy charity Transform. That vaping can reduce smoking is backed up by data from Australia, where vapes were effectively banned in 2021 and the result has been no cut in smoking – indeed, there’s been a small rise.

For all that, more than 6 million Britons still smoke, their burden on the NHS relieved only by their paying £10bn in tobacco taxes and dying – on average – younger. Despite the comfort smoking has long brought to many people – not everyone is a nicotine addict – there must be a public interest in discouraging its consumption. In its lengthy study of this debate, Transform comes down firmly in favour of simply extending what has worked. When in 2007 Britain raised the age from 16 to 18 it led to an estimated 30% fall in smoking by that age group, a remarkable achievement. In the US, raising the age to 21 in 2019 led to an even greater fall of 39%. A similar raise to 21 is surely what the British government should now do. Unlike Sunak’s staggered ban, which may take five years to take effect, this change could be introduced at once. The only other country to propose his “ID-card ban” has been New Zealand. Its unpopularity and a change of government have seen it abandoned .

We also see the heavy hand of the state in Britain’s failed drugs policies. The global “war on drugs” has been an unmitigated disaster, built as it was on the thesis that demand would end if supply was stamped out. The only regime to prove remotely effective in curbing supply is the Taliban in Afghanistan – and that may not last. Politicians everywhere have preferred to see gangsters triumph, crime soar, jails become crammed and their children ruined, rather than show the guts to decriminalise , regulate and control the hugely lucrative and dynamic drugs industry.

Governments across Europe – most recently in Germany – are testing how to handle recreational and other sorts of drug. They are experimenting with licensing, taxation, product regulation, publicity and public education. Some approaches work, some do not. The British government has adopted a workable policy on the smoking of tobacco by young people. Its record on nicotine control is widely regarded as a success – as its record on other narcotics is a raging failure. As Transform points out, “Tobacco control … is one key aspect of drug policy where the UK has not been shockingly poor by global standards.” The reason appears to be that it has treated “smoking as a public health challenge, led by health agencies, rather than an enforcement challenge led by the Home Office”. Sunak’s smoking ban would have the same defects as the cannabis ban. Complicated government is always bad government.

Tobacco control offers an intriguing testing ground for what is now the fast-liberalising market for drugs across Europe. Realistic and fair regulation will be hard but it must come in if millions are not to die prematurely. The misuse of opioids is now approaching pandemic status across the US.

At every turn, the state is inviting itself to delve ever deeper into the lives and ethics of its citizens – accusations that are constantly thrown at authoritarian governments. It seeks to relieve us of responsibility for personal decisions and deny us freedom of choice. It rules on the food we eat and the drinks we drink, on the right to criticise and on how we discipline or indulge our children. Britain does not need gimmicks such as cigarette passports. Tobacco is a menace but one that’s on the way out. Other addictions should now claim our attention.

Simon Jenkins is a Guardian columnist

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Tobacco control policies in the 21st century: achievements and open challenges

Armando peruga.

1 Tobacco Control Research Group, Epidemiology and Public Health Research Programme, Institut d'Investigació Biomèdica de Bellvitge‐IDIBELL, Barcelona Spain

2 Consortium of Centers for Biomedical Research on Respiratory Diseases (CIBERES), Madrid Spain

3 Center for Epidemiology and Health Policies, Clínica Alemana School of Medicine, Universidad del Desarrollo, Santiago Chile

María José López

4 Evaluation and Intervention Methods Service, Agència de Salut Pública de Barcelona, Spain

5 Consortium of Centers for Biomedical Research on Epidemiology and Public Health, CIBERESP, Madrid Spain

6 Institut d'Investigació Biomèdica de Sant Pau (IIB Sant Pau), Barcelona Spain

Cristina Martinez

7 Tobacco Control Unit, WHO Collaborating Center on Tobacco Control, Institut Català d'Oncologia‐ICO, Barcelona Spain

8 School of Medicine and Health Sciences, Campus of Bellvitge, Universitat de Barcelona, Spain

Esteve Fernández

Noncommunicable diseases (NCDs), including cancer, are responsible for almost 70% of all deaths worldwide. Tobacco use is a risk factor common to most NCDs. This article discusses tobacco control policies and highlights major achievements and open challenges to reduce smoking prevalence and attributable morbidity and mortality in the 21st century. The introduction of the WHO Framework Convention on Tobacco Control in 2005 has been a key achievement in the field and has already facilitated a drop in both smoking prevalence and exposure to secondhand smoke. Indicatively, the size of the worldwide population benefiting from at least one cost‐effective tobacco control policy has quadrupled since 2007. In addition, plain cigarette packaging has been successfully introduced as a tobacco control policy, surmounting efforts of the tobacco industry to challenge this based on trade and investment law. Nevertheless, tobacco control still faces major challenges. Smoking prevalence needs to be further reduced in a rather expedited manner. Smoke‐free environments should be extended, and the use of plain tobacco packaging with large pictorial health warnings for all tobacco products should be further promoted in some parts of the world. Some of these measures will require prompt determination and diligence. For example, bold political decisions are needed to significantly increase real prices of tobacco products through excise taxes, ban added ingredients that are currently used to increase the attractiveness of tobacco products and ban the tobacco industry's corporate social responsibility initiatives. Finally, the debate on harm reduction strategies for tobacco control still needs to be resolved.

Tremendous, although insufficient, progress has been made on tobacco control during the past twenty years. Nevertheless, there are still open challenges, and several measures remain to be implemented soon: increasing tobacco taxes, banning the use of additives, implementing plain packaging, banning tobacco industry's corporate social responsibility activities, and counteracting the undermining tactics of the tobacco industry.

Abbreviations

1. introduction.

The 1964 US Surgeon General's Report [ 1 ] and numerous other reports have established the terrible consequences of smoking on the health of smokers and nonsmokers. At the end of the 20th century, tobacco had caused 100 million deaths worldwide, becoming a leading cause of totally preventable premature deaths. It has been predicted that without any additional tobacco control efforts, one billion people could die from causes related to tobacco by the end of the 21st century, such as cancer, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease [ 2 ].

An extremely profitable industry fueled the tobacco epidemic by selling a highly addictive product taking advantage of globalization in the second half of the 20th century. Governments and public health organizations became aware of the globalization and the severe consequences of the tobacco epidemic and its evolution into a large‐scale pandemic [ 3 ]. The significant economic toll of tobacco, which today amounts to US$1436 billion, or 1.8% of the world's annual gross domestic product [ 4 ], was soon realized. At the same time, governments and public health organizations recognized that the pandemic needed a global and coordinated high‐level response.

In 1999, WHO initiated the proceedings to create the Framework Convention for Tobacco Control (FCTC), the first international treaty under WHO auspices. Followingly, the global community recognized tobacco use as a severe threat to global health, as well as a social and economic problem, and began to take joint international action. This work highlights achievements in tobacco control in the 21st century and discusses open challenges (Fig.  1 ).

Tremendous, although insufficient, progress has been made on tobacco control during the past 20 years. Nevertheless, there are still open challenges, and several measures remain to be implemented soon: increasing tobacco taxes, banning the use of additives, implementing plain packaging, banning tobacco industry's corporate social responsibility activities, and counteracting the undermining tactics of the tobacco industry.

2. Achievements of tobacco control efforts during the first 20 years of the 21st century

2.1. galvanizing global political will around international law.

The WHO FCTC entered into force in 2005 as binding law for all treaty parties. As of January 2021, the treaty was adopted by 181 WHO member states and the European Union, thereby covering more than 90% of the world's population. The Protocol to Eliminate Illicit Trade in Tobacco Products, also known as Illicit Trade Protocol (ITP), was introduced under the WHO FCTC in 2018. As of January 2021, 62 WHO FCTC parties had also become parties to the protocol.

Galvanizing the global political will for implementing the WHO FCTC and the ITP has been a key success in tobacco control. These treaties redefine the role of international law in preventing disease and promoting health. Both treaties seek to establish cooperation among countries to tackle, for example, cross‐border advertising and illicit trade. Importantly, they seek to establish international cooperation on matters that would otherwise be subject to national regulation because the sovereignty of nations to protect public health is often challenged by the interests of the powerful transnational tobacco industry. The tobacco companies often seek to expand the tobacco market through various tactics, including intensive targeting of women, children, and the poorer parts of society [ 5 ]. Therefore, the WHO FCTC and the ITP have solidified global governance of health matters and the foundation for countries to enact comprehensive, effective national tobacco control measures that span across all government sectors.

2.2. Quadrupling the number of people benefiting from at least one cost‐effective tobacco control policy since 2007

In 2008, WHO introduced the MPOWER package to assist in implementing the six best‐practice cost‐effective interventions defined in the WHO FCTC. The six MPOWER measures are as follows: (a) Monitor tobacco use and prevention policies (M); (b) Protect people from tobacco smoke (P); (c) Offer help to quit tobacco use (O); (d) Warn about the dangers of tobacco (W); (e) Enforce bans on tobacco advertising, promotion and sponsorship (E); and (f) Raise taxes on tobacco (R) (see Table  1 for an overview of MPOWER measures and how they relate to the WHO FCTC provisions) [ 6 ]. To track the global improvement in the implementation of MPOWER measures, WHO measures the level of policy achievement for each measure in each country. In each country, an MPOWER measure is considered to be mandated at the highest level when the law requires implementing all policy components that render such measure most efficacious in reducing the demand for tobacco products, that is, reducing the prevalence of tobacco use. For example, the MPOWER measure to protect the population from tobacco smoke is mandated at the highest level when the law requires a complete indoor smoking ban for all workplaces and public places and not only for some of them. Similarly, the measure to warn about the dangers of tobacco is mandated at the highest level when the law requires that health warnings cover an average of at least 50% of the front and back of the package and has four or more desired features. These features include changing the health warning periodically or including pictures or pictograms. Tobacco taxes are mandated at the highest level when excise tobacco taxes amount to at least 75% of the retail price of a cigarette pack. The closer each country is to the highest level of policy achievement, the higher is the MPOWER score the country receives. A detailed description of the MPOWER scores has been explained elsewhere [ 7 ].

Description of the WHO FCTC articles and their inclusion in the MPOWER measures.

About 5 billion people living in 136 countries, an equivalent to 65% of the world's population, are currently benefiting from at least one of these MPOWER measures implemented at the highest level. This is a fivefold increase from the 1.1 billion people benefiting from tobacco control measures back in 2007.

The world's population profiting from a basic comprehensive policy to assist smoking cessation, or a comprehensive ban of tobacco advertising, promotion, and sponsorship has increased about sixfold between 2007 and 2018. The proportion of the world's population benefitting from a comprehensive smoke‐free policy or a legal mandate to have large graphic labels with strong health warnings on tobacco packages has increased more than eight times in the same period.

While the increase in cigarette taxes is the most effective tobacco control measure [ 8 ], it was also the least applied in 2018. The total population worldwide affected by a cigarette tax representing at least 75% of the retail price has almost doubled since 2007. Another way to look at the impact of tobacco taxes is to assess whether tax increases are able to decrease the affordability of tobacco products. By 2018, 44.3% of the global population lived in countries where cigarettes became less affordable in the last 10 years. However, most decreases in cigarette affordability were small. When considering at least a 10% relative decrease in cigarette affordability, the world's population living in countries achieving this breakthrough is 3.1% [ 7 ].

Noticeably, the proportion of the world's population exposed to a best‐practice mass media campaign decreased from 2010 until 2018. Few countries run mass media campaigns regularly, probably due to the high costs of such campaigns. Only four countries (Australia, Turkey, the United Kingdom, and Viet Nam) have run best‐practice mass media campaigns repeatedly since 2010.

2.3. Reducing the prevalence of smoking and exposure to secondhand smoke

According to the latest WHO estimates that compared smoking prevalence across countries in 2015, the age‐standardized prevalence of current tobacco smoking had decreased gradually by 5.9 percentage points since the beginning of the 21st century, that is, a relative reduction of 25% or an average decrease of 0.4 percentage points per year. WHO estimates that 19.8% of the world's population aged ≥ 15 years were current smokers in 2015 [ 9 ]. Denmark, Norway, and Uruguay were the only countries where current smoking prevalence among persons aged ≥ 15 years had been reduced by ten or more percentage points between 2005 and 2015. During this period, Denmark and Panama approached most closely the endgame prevalence target of 5%, covering more than half of the gap between current smoking prevalence and target [ 10 ].

A recent study [ 11 ] estimated that in countries with higher initial tobacco control preparedness, as measured by an early MPOWER implementation, the prevalence of daily smoking decreased by between 0.39 and 0.50 percentage points for each increase in the MPOWER score, which indicates the strength of the adopted policies. By contrast, countries with initially low tobacco control preparedness and high daily smoking prevalence seem to be struggling to reduce prevalence despite progress in MPOWER implementation. Another study indicated that the adoption of at least one highest level MPOWER policy in 88 countries between 2007 and 2014 resulted in almost 22 million fewer projected smoking‐attributable deaths [ 12 ].

The health impact of smoke‐free policies has been impressive. The proportion of people protected by smoke‐free legislations worldwide has increased from 3.0% in 2007 to 21.1% in 2018 (Table  2 ). The largest countries in the world report significant decreases in the proportion of people exposed to secondhand smoke [ 13 , 14 , 15 , 16 ]. Existing evidence shows that countries that enact national legislative smoking bans reduce the population exposure to passive smoke and benefit from improved health outcomes, specifically of cardiovascular diseases [ 17 ].

Global progress in the implementation of selected tobacco control policies at the highest level a . Change between 2007 and 2018 in the population living in countries with selected policy in billions and as a percentage of the world's population.

2.4. Tobacco plain packaging has resisted challenges under trade and investment law

In 2012, Australia became the first country to implement tobacco plain packaging to counter the tobacco industry's use of packaging for both selling cigarettes and undercutting health warnings. The Australian legislation bans logos, brand imagery, symbols, other images, colors, and promotional text on tobacco products and tobacco product packaging. It also requires that graphic health warnings cover 75% of the front and 90% of the back of the tobacco pack [ 18 ].

Australia's plain packaging legislation underwent three sets of legal challenges. First, big tobacco companies filed a lawsuit in the Australian High Court. Second, Philip Morris Asia sought to bring down the Australian legislation under an existing investment treaty between Australia and Hong Kong. Third, Cuba, the Dominican Republic, Honduras, Indonesia, and Ukraine filed a dispute through the World Trade Organization (WTO). The constitutional challenge was dismissed in August 2012 [ 19 ], and the investment challenge was rejected in December 2015 [ 20 ]. The WTO decided in June 2020 that Australia's plain packaging laws are likely to improve public health and that they are not unfairly restrictive to trade [ 21 ]. The decisions in the case of Australia are not just a success for public health. They also bring hope for continuing efforts to defend tobacco control policies against the attempts of the wealthy tobacco transnationals.

3. Immediate challenges for further reducing the burden to tobacco‐attributable diseases

The successes described above are significant accomplishments. However, key challenges still need to be addressed to reduce the burden of tobacco‐attributable diseases worldwide in a timely manner.

3.1. Accelerating the decline of smoking prevalence

The WHO set a relative reduction goal of 30% in tobacco use and smoking for the period between 2010 and 2025 [ 22 ]. Accordingly, the global prevalence of current smokers should be 15.1% by 2025. However, based on existing trends, the WHO projects that current smokers would be 17.1% of the global population by 2025 [ 7 ]. Therefore, the projected decrease is not fast enough to reach the 2025 reduction goals set by the WHO.

The reduction in smoking prevalence has been, so far, attributed primarily to the increase in the total population and not necessarily to a reduction in the number of smokers. It is projected that the total number of smokers will decrease from 1082 million in 2000 to 1058 million in 2025, a reduction of about 24 million or 2.2% [ 7 ]. While the number of smokers in the Americas and Europe will substantially decrease, a net increase in male smokers in the African, Eastern Mediterranean, and South‐East Asian regions is expected to hinder a more significant global decrease. Considering these figures, and that almost one third of the countries of the world—59 countries in total—have not yet adopted any MPOWER measures at the highest level of achievement, the implementation of cost‐effective tobacco control measures needs to be expedited.

Strengthening tobacco denormalization through smoke‐free environments and disseminating plain packaging and large pictorial warnings for all tobacco products could spearhead progress in many countries. It seems, however, that a few measures will require prompt unique determination and diligence. In our opinion, bolder moves are needed to:

• significantly increase real prices of all tobacco products through tobacco taxes. Since increasing taxes is the most effective tobacco control measure, the tobacco industry devotes many efforts to derail this measure [ 23 , 24 ]. The main tactics employed by these companies depend on the tax structure and administration of each country and the type of competition they face from other manufacturers [ 25 ].
• disrupt strategies currently applied to engineer the attractiveness of tobacco products by banning ingredients that may increase their palatability, including additives and particularly characterizing flavors.
• ban the most insidious form of tobacco promotion: the tobacco industry's corporate social investment or responsibility (CSR) initiatives. The tobacco industry has always conceived CSR as a public relations tool to further its business objectives [ 26 ]. It is a form of advertising, promotion, and sponsorship that should be banned. Whether supporting empowering women [ 27 ], disaster relief and preparedness [ 28 ], infectious disease prevention [ 29 ], or efforts against COVID‐19 [ 30 ], the tobacco industry's CSR activities do little to address the death and suffering caused by tobacco use [ 31 ].

To accelerate the implementation of these and other measures and the decline of smoking, some consider that a harm reduction strategy should be added to the existing mix of policies. A harm reduction approach to tobacco control encourages those smokers that cannot or are unwilling to stop smoking to switch to using nicotine in a less harmful form than combustible tobacco [ 32 ]. The public health community is divided over the value of such a strategy within the parameters of the existing alternative products, market forces driving the use of all tobacco and nicotine products, the strength of tobacco control policies, and the room of these to significantly and quickly drive a reduction in smoking [ 33 ]. Resolving this debate is a challenge too. Meanwhile, there are at least three things that should be considered to expedite the implementation of the WHO FCTC, as discussed below.

3.2. Positioning tobacco control in the global health and development agendas

The global success of the WHO FCTC will be partially determined by the extent to which governments and the international community realize that the tobacco pandemic is a threat to development and the achievement of the United Nations Sustainable Development Goals (SDG) [ 34 ]. Tobacco use increases healthcare costs and decreases productivity. Moreover, it feeds into the vicious circle of poverty. The most disadvantaged people spend comparatively less on necessities such as food, education, and health care to pay for their addiction to tobacco products [ 35 ]. Furthermore, tobacco farming destroys the environment upon which the poorest rely to survive. The large amounts of pesticides and fertilizers required to grow tobacco are toxic and pollute water supplies, in addition to the deforestation of their habitat to make room for a nonstaple crop and to cure tobacco [ 36 ]. Despite the inclusion of a specific target for implementing the WHO FCTC in the SDGs, for most governments, tobacco control remains merely a health issue instead of a development goal [ 37 ].

Noncommunicable diseases presently make up 7 of the world's top ten causes of death, and tobacco use is a risk factor for many NCDs [ 38 ]. However, tobacco control is often not prioritized in the health policy agenda [ 32 ]. The global health agenda is presently dominated by the ‘unfinished agenda’ of communicable disease and maternal and child health in low‐ and middle‐income countries. Considering the threats of tobacco use to the public health systems, tobacco control's contribution to building stronger economies and more equitable societies will help to address the ‘unfinished agenda’ and will be crucial for the recovery from the COVID‐19 pandemic in low‐ and middle‐income countries [ 39 ].

The exposure of high‐income countries to the COVID‐19 pandemic has highlighted the importance of controlling communicable diseases also in these nations. However, this should not distract us from the fact that COVID‐19 has hit the hardest people with NCDs, for which tobacco use is the main common risk factor. Smoking increases the risk of hospitalization, disease severity, and mortality from COVID‐19 [ 40 ]. Therefore, the COVID‐19 pandemic highlights the importance of investing equal efforts in tackling communicable diseases and NCDs, as the latter impact on the health outcomes of the former, as well as on the capacity of healthcare systems.

Tobacco control, and NCD prevention, in general, involves the regulation of industries that produce goods whose consumption may affect human health. Some of these industries and their allies are self‐servingly reminding us that the priority for global health is to prevent communicable disease [ 41 ] and responding quickly and decisively to outbreaks [ 42 ] instead of tobacco control or NCDs [ 43 , 44 ].

3.3. Overcoming the false ‘health versus economy’ dilemma: the need for a whole‐government approach

The response to the COVID‐19 pandemic has made us painfully aware of the fallacy of presenting the response to health problems as a trade‐off between lives saved and the economic cost of trying to save those lives—the health versus the economy dilemma. Positioning tobacco control within the overall—mainly economic—priorities of each government is a challenge, mainly given the intricacies of the broader context of the economic globalization that governments must navigate.

Parties to the WHO FCTC recognize that a critical challenge to implementing the treaty in their countries is the weakness of their multisectoral coordination and the insufficient support to the implementation of the WHO FCTC from sectors outside health [ 45 ]. A whole‐government approach is needed to succeed in declining smoking prevalence.

3.4. Countering the Tobacco Industry's Tactics to undermine tobacco control measures

The interests of the tobacco industry are irreconcilable with tobacco control and public health [ 46 ]. Consequently, governments should protect the implementation of their tobacco control policies from the commercial and other vested interests of the tobacco industry as mandated by the WHO FCTC. Countering the tobacco industry's tactics to undermine tobacco control measures is not a new challenge [ 47 ], but it has evolved with time. From the same that claimed at some point that tobacco is not damaging to health [ 48 ], nor addictive [ 49 ] or denied targeting youth [ 50 ], we get now that they are committed to a ‘smoke‐free future’ [ 51 ]. Their claims are not credible as long as the industry continues to fight proven policies and programs that reduce smoking. Equally, their proclamations are not convincing while they misrepresent regulatory agency decisions about the novel tobacco products such as heated tobacco products as less harmful than cigarettes [ 52 ]. Ultimately, if anyone in the tobacco industry is really dedicated to a smoke‐free future, it should immediately stop all marketing of any kind of cigarettes.

4. Conclusions

Tremendous, although insufficient, progress has been made on tobacco control during the past twenty years (Fig.  1 ). Nevertheless, there are still open challenges, and several measures remain to be implemented soon: increasing the real price of all tobacco products through tobacco taxes, banning the use of additives in tobacco products, implementing plain packaging for all tobacco products, and banning tobacco industry's corporate social responsibility activities. While implementing these measures, governments and public health policymakers should be prepared to counteract undermining tactics of the tobacco industry.

Conflict of interest

The authors declare no conflict of interest.

Author contributions

AP, MJL, CM, and EF contributed to the conception and outline of the manuscript. AP prepared the first version of the manuscript. AP, MJL, CM, and EF edited and revised the manuscript, and approved its final version.

Acknowledgements

The Tobacco Control Research Group is partly supported by the Ministry of Business and Knowledge from the Government of Catalonia [2017SGR319] and by Instituto de Salud Carlos III, Government of Spain (CIBERES CB19/06/00004). EF was also supported by the Instituto de Salud Carlos III, Government of Spain, co‐funded by the European Regional Development Fund (FEDER) [INT16/00211 and INT17/00103]. CM was also supported by the Instituto de Salud Carlos III, Government of Spain, co‐funded by the European Regional Development Fund (FEDER) [INT17/00116] and Ministry of Health from the Government of Catalonia [PERIS No. 9015‐586920/2017]. We thank CERCA Programme/Generalitat de Catalunya for institutional support.