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Disclaimer All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office [GPO], Washington, DC 20402-9371; telephone: [202] 512-1800. Contact GPO for current prices.Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development2. Here we show that comprehensive tobacco control policies—including smoking bans, health warnings, advertising bans and tobacco taxes—are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.
Decades after its ill effects on human health were first documented, tobacco smoking remains one of the major global drivers of premature death and disability. In 2017, smoking was responsible for 7.1 [95% uncertainty interval [UI], 6.8–7.4] million deaths worldwide and 7.3% [95% UI, 6.8%–7.8%] of total disability-adjusted life years3. In addition to the health impacts, economic harms resulting from lost productivity and increased healthcare expenditures are also well-documented negative effects of tobacco use4,5. These consequences highlight the importance of strengthening tobacco control, a critical and timely step as countries work toward the 2030 Sustainable Development Goals2. In 2003, the World Health Organization [WHO] led the development of the Framework Convention on Tobacco Control [FCTC], the first global health treaty intended to bolster tobacco use curtailment efforts among signatory member states1. Later, in 2008, to assist the implementation of tobacco control policies by countries, the WHO introduced the MPOWER package, an acronym representing six evidence-based control measures [Table 1] [ref. 6]. While accelerated adoption of some of these demand reduction policies was observed among FCTC parties in the past decade7, many challenges remain to further decrease population-level tobacco use. Given the differing stages of the tobacco epidemic and tobacco control across countries, consolidating the evidence base on the effectiveness of policies in reducing smoking is necessary as countries plan on how to do better. In this study, we evaluated the association between varying levels of tobacco control measures and age- and sex-specific smoking prevalence using data from 175 countries and highlighted missed opportunities to decrease smoking rates by predicting the global smoking prevalence under alternative unrealized policy scenarios. Table 1 The WHO MPOWER policy package Full size tableMain
Despite the enhanced global commitment to control tobacco use, the pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, sex and age8; in 2017, there were still 1.1 billion smokers across the 195 countries and territories assessed by the Global Burden of Diseases, Injuries, and Risk Factors Study. Global smoking prevalence in 2017 among men and women aged 15 and older, 15–29 years, 30–49 years and 50 years and older are shown in Extended Data Figs. 1, 2, 3 and 4, respectively. We found that, between 2009 and 2017, current smoking prevalence declined by 7.7% for men [36.3% [95% UI, 35.9–36.6%] to 33.5% [95% UI, 32.9–34.1%]] and by 15.2% for women globally [7.9% [95% UI, 7.8–8.1%] to 6.7% [95% UI, 6.5–6.9%]]. The highest relative decreases were observed among men and women aged 15–29 years, at 10% and 20%, respectively. Conversely, prevalence decreased less intensively for those aged over 50, at 2% for men and 9.5% for women. While some countries have shown an important reduction in smoking prevalence between 2009 and 2017, such as Brazil, suggesting sustained progress in tobacco control, a handful of countries and territories have shown considerable increases in smoking rates among men [for example, Albania] and women [for example, Portugal] over this time period.
In an effort to counteract the harmful lifelong consequences of smoking, countries have, overall, implemented stronger demand reduction measures after the FCTC ratification. To assess national-level legislation quality, the WHO attributes a score to each of the MPOWER measures that ranges from 1 to 4 for the monitoring component [M] and 1–5 for the other components. A score of 1 represents no known data, while scores 2–5 characterize the overall strength of each measure, from the lowest level of achievement [weakest policy] to the highest level of achievement [strongest policy]6. Between 2008 and 2016, although very little progress was made in treatment provision [O]7,9, the share of the total population covered by best practice [score = 5] P, W and E measures increased [Fig. 1]. Notably, however, a massive portion of the global population is still not covered by comprehensive laws. As an example, less than 15% of the global population is protected by strongly regulated tobacco advertising [E] and the number of people [2.1 billion] living in countries where none or very limited smoke-free policies [P] are in place [score = 2] is still nearly twice as high as the population [1.1 billion] living in locations with national bans on smoking in all public places [score = 5].
Fig. 1: Level of coverage of the population aged 15 years and older by comprehensive smoke-free, health warning and advertising policies in 2008 and in 2016.
To assess national-level legislation quality, the WHO attributes a score to each MPOWER component that ranges from 1 to 5 for smoke-free [P], health warning [W] and advertising [E] policies. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from 2 representing the lowest level of achievement [weakest policy], to 5 representing the highest level of achievement [strongest policy].
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In terms of fiscal policies [R], the population-weighted average price, adjusted for inflation, of a pack of cigarettes across 175 countries with available data increased from I$3.10 [where I$ represents international dollars] in 2008 to I$5.38 in 2016. However, from an economic perspective, for prices to affect purchasing decisions, they need to be evaluated relative to income. The relative income price [RIP] of cigarettes is a measure of affordability that reflects, in this study, what proportion of the country-specific per capita gross domestic product [GDP] is needed to purchase half a pack of cigarettes a day for a year. Over time, cigarettes have become less affordable [RIP 2016 > RIP 2008] in about 75% of the analyzed countries, with relatively more affordable cigarettes concentrated across high-income countries.
Our adjusted analysis indicates that greater levels of achievement on key measures across the P, W and E policy categories and higher RIP values were significantly associated with reduced smoking prevalence from 2009 to 2017 [Table 2]. Among men aged 15 and older, each 1-unit increment in achievement scores for smoking bans [P] was independently associated with a 1.1% [95% UI, −1.7 to −0.5, P