Evidence-Based Strategies to Reduce Global Tobacco Use

Hand holding up no smoking sign with people walking around outside in the background.
Smoking is one of the deadliest – but most preventable – public health crises. Fortunately, there are many evidence-based tools that have proven to curb tobacco usage.

Tobacco use is a serious global public health emergency. With the World Health Organization (WHO) estimating tobacco-related deaths at more than 8 million people a year globally, leaders from around the world need to take action to reduce distribution and demand, says Vaughan Rees, Director, Center for Global Tobacco Control, Harvard T.H. Chan School of Public Health.

He points out that unlike other global epidemics, the tobacco crisis is a consequence of deliberate actions by the tobacco industry—and their efforts target the most vulnerable populations, including adolescents, people from low income backgrounds, people with a history of substance abuse, and individuals who struggle with mental health.

Understanding the Tobacco Control Landscape

Rees says it is essential that health care leaders, politicians, and government officials from both established and developing countries understand the tobacco landscape and know how best to develop an effective response based on the latest evidence-based approaches. The most impactful tobacco control strategies must also be targeted to address a nation’s or region’s cultural, social, and economic realities, he adds.

“Almost 14 percent of adults, and 5 percent of youth in the U.S. use tobacco, but the problem doesn’t look the same in all parts of the world,” Rees explains. There are different rates of use, different products used, different social and religious attitudes, and different laws and regulations. Further complicating matters is that different global regions may be in different phases of the tobacco crisis.

“The good news is that there is a wide range of evidence-based tools available and we know what works,” Rees says. But the challenge lies in getting the right tools into the hands of the people who are in a position to use them effectively and making sure they will be the right fit for the needs of each country in which they are applied.

“Almost 14 percent of adults, and 5 percent of youth in the U.S. use tobacco, but the problem doesn’t look the same in all parts of the world. The good news is that there is a wide range of evidence-based tools available and we know what works.”

Addressing the Supply and Demand for Tobacco

To help accomplish this goal, the WHO created a Framework Convention on Tobacco Control (FCTC), the first international treaty focused on a public health issue. FCTC became active in 2005 and addresses both the supply and demand for tobacco through a series of regulatory, lifestyle, and educational components.

“Many countries have ratified the treaty as part of their commitment to reduce the burden of tobacco use,” Rees says, adding that the United States is one of only a few that did not join the conversation, although we have provided leadership in global tobacco control efforts.

The FCTC initiative provides technical assistance to countries that need help implementing tobacco control and prevention efforts and responding to the extreme burden tobacco places on their health systems and economies.

“We can save many lives and prevent many people from having a lifetime of suffering due to chronic diseases caused by smoking if we can get better control of tobacco distribution and use, and communicate the risks more effectively,” Rees says.

Introducing Tobacco Control and Prevention Strategies

As part of its efforts, FCTC has developed a program called MPOWER, which is a set of strategies based on six key pillars of influence in the tobacco control field. These strategies, which are described on the WHO website provide a strong framework that leaders can adapt to meet their region’s needs. The list includes:

  • Monitoring tobacco use and prevention policies in each country to gather a clear picture of the situation and tailor the response as needed for best results.
  • Protecting people from the harms of second-hand tobacco smoke by implementing no-smoking policies to improve health and outcomes.
  • Offering access to smoking-cessation programs for people addicted to tobacco in order to help them quit.
  • Warning about the dangers of tobacco use by including health warnings on packaging, using anti-smoking advertising, and encouraging the media to share messages about the harms associated with smoking.
  • Enforcing a total ban on advertising, promotion, and sponsorship of tobacco, which has been found to be very effective in reducing use, especially among young people.
  • Raising taxes on tobacco to increase the overall price, which has been found to be the single most effective approach in reducing tobacco use, and preventing children from starting to smoke. The revenues can also be directed to fund tobacco prevention and tobacco control programs.

“We can save many lives and prevent many people from having a lifetime of suffering due to chronic diseases caused by smoking if we can get better control of tobacco distribution and use, and communicate the risks more effectively.”

The Tobacco Pandemic Differs by Region

While all of these points are key parts of a comprehensive tobacco control strategy, Rees stresses that this is not a one-size-fits-all situation. “Smoking is really a social equity issue that has hit different regions at a different pace,” he says. Therefore, every nation has to decide on which elements make the most sense for them to focus on for their current situation and to adapt them so that they are socially and culturally relevant and meet the current needs that exist.

For instance, Rees says the tobacco pandemic has peaked in developed countries like the U.S., Canada, and Australia, while other countries are in earlier stages of the pandemic, so they will require a different level of intervention.

“In Ethiopia and some other African countries, for example, right now there is a low prevalence of smoking, but the problem is on the rise. Tobacco manufacturers are knowingly targeting vulnerable people in these countries with strategies that have been used previously in the U.S.,” he says. “In low-income and developing countries especially, it takes considerable support, care, and evidence to know how to approach the challenges most effectively.”

There are also certain cultural differences in how tobacco is marketed and how it is used. For instance, in India, smokeless tobacco products are the norm and usage is predominantly among the affluent population, while in the U.S., smokers are more likely to be low-income, Rees says. Leaders need to take all of these types of variables into account when developing a response.

The Promise of Tobacco Taxes

Taxes are a particularly potent strategy to reduce demand for tobacco use globally, Rees says, but he adds that this can be controversial, especially in developing countries that are very dependent on the money tobacco taxes contribute to their economies. Yet he explains that when you weigh the profits against the costs—such as chronic illness, reduced productivity, and premature death—the costs of tobacco harm actually outweigh any financial benefits. Nonetheless, in some countries there is a lot of pushback to raising taxes since people complain such a price hike places an unfair burden on low-income families.

Rees also says that when exploring the tobacco landscape, it’s important to also understand that some of developed nations are looking toward the end of the tobacco crisis, which may occur over the next few decades.

“Part of the ‘end game’ is the idea of tobacco harm reduction,” he says—such as the adoption of smokeless or electronic devices to deliver nicotine with lower exposure to carcinogens and other toxic chemicals. This is worth considering for some countries as they seek to address the harm associated with tobacco use.

Creating a Tobacco Control Framework

Despite all of the complexities involved in the tobacco landscape, Rees’ advice for leaders who want to address tobacco control issues is simple: They need to look at the trends in their own country and determine how the MPOWER strategies can best be developed into a framework that fits their current realities.

“The health burden associated with tobacco use is second to none globally,” he says. But with a concerted effort, leaders can reduce the demand for tobacco, minimize harm, reduce costs to health systems and ultimately, save lives.