In the fights against smoking, the World Health Organization appears to measure success in bureaucratic rather than human terms.
By George Gay
As I get older, I have a growing problem whereby my thought processes move into circular orbits around my head. For instance, I have been reading the 2019 World Health Organization’s (WHO) tobacco report and, while you might expect it to contain much food for thought, just about the only question that is doing the rounds in my mind is: Why does the report contain so many pictures of children (and to be clear, I’m talking about preteen children)? There are so many such pictures that I gave up counting less than halfway through the 200-page online version of the WHO report on the global tobacco epidemic 2019, by which time I had totted up 50 smiling children.
Don’t get me wrong, such pictures, with their air of joy and hope, can brighten the darkest days even for an old cynic. But there is a time and a place, and I thought that mixing such pictures with tobacco was a no-no, unless overwhelming evidence could be presented to support the idea that such juxtapositions would have a significant positive outcome for children in general.
So, perhaps I wouldn’t have questioned the placement of the pictures if the underlying theme of the report had been the prevention of smoking initiation among children, but it wasn’t, and the use of the pictures seemed gratuitous. The theme was “offer help to quit tobacco use,” a seemingly tortuous effort to justify the ‘O’ in ‘MPOWER,’ which was said in a foreword by WHO Director General Tedros Adhanom Ghebreyesus to encompass six measures to help implement the WHO’s Framework Convention on Tobacco Control (FCTC) using “effective interventions that are proven to reduce demand for tobacco.”
To my mind, this foreword is a strange piece in which “success” seems to be measured in bureaucratic terms—in respect of how many countries have been encouraged to implement MPOWER measures—rather than in human terms—the number of people who quit smoking, which doesn’t get a mention.
It seems a strange thing to say, but the FCTC doesn’t seem to do humanity. Rather than try to get to the bottom of why people smoke and help address the issues they have, it encourages governments to threaten them with graphic images of diseases and tax them until they bleed through the eyes. It seems not to be on the side of the smoker but on the side of some greater calling. It seems to be on the side of tobacco manufacturers, through its Protocol to Eliminate the Illicit Trade in Tobacco, and on the side of governments and their revenues, which many spend not on programs to prevent tobacco initiation among smiling children but on armaments, some of which end up blowing the limbs off those children. I suppose you can’t smoke if you don’t have any fingers.
The closest the director general comes to talking about getting smokers to quit their habit is when he suggests that due in part to countries implementing MPOWER measures, “many tobacco users now want to quit, and we know how to help them.” To my mind, the lack of urgency and ambition in this statement beggars belief. But then I guess it’s easy to get used to failure. Part of the summary of the report has this to say: “Unfortunately, only 13 new countries have started providing comprehensive cessation programs since 2007. There are now 23 countries protected by this measure, up from 10 countries in 2007.” At this point, you start to wonder whether the children are pictured because this report is meant to be read by them—or, more likely, only by the very youngest among them. After all, I assume that adults and most children would not need to be told that if a number has increased from 13 to 23, the original number was 10.
The forewords by Michael R. Bloomberg, WHO global ambassador for noncommunicable diseases and injuries and founder of Bloomberg Philanthropies, and Vera Luiza da Costa e Silva, head of the WHO FCTC Secretariat, also seem to measure success in getting countries to implement FCTC policies, and the nearest they get to talking about the numbers of people who have quit—or who would have quit if only—is when the latter says, “If tobacco cessation measures had been adopted at the highest level of achievement in 14 countries between 2007 and 2014, 1.5 million lives could have been saved.” I’m sure that if they could speak, those 1.5 million people would want to thank da Costa e Silva for her encouraging words.
The three forewords run to about 1,750 words, and, despite the number of pictures of children in the report, the word “children” occurs only once in those forewords when da Costa e Silva claims the tobacco industry doesn’t want anything to change, but “for the sake of public health, and in the interests of our children and future generations, things must change.”
Ah, change; it’s all very well, but you do have to be careful what you wish for. In his foreword, Bloomberg highlights some of the WHO’s most important gains, one of which has occurred in Brazil, which “is now the second country [after Turkey] … that has passed all MPOWER policies at the highest level.” It’s true. Policies in Brazil do seem to have changed to ensure that fewer of its children will die of tobacco-related diseases, but mainly, I would suggest, because they will firstly fall victim to the effects of climate change-induced environmental disasters, in which, in fairness, many other countries will be complicit.
As usual, the United Nations is protecting us from things we can protect ourselves from, but leaving us exposed to those that we cannot: climate change, environmental breakdown, pollution, poverty, globalized viruses and those endless bombs sold, according to the logic of the market economy, to any lunatic group with the money to buy them. There is little sense that we should be in preventative rather than reactive mode. When I see the pictures of the WHO’s smiling children, I cannot get out of my mind the faces of children I see in my newspaper: terrified, dirty faces above malnourished, shabbily clothed bodies wandering among rubble-strewn streets a million miles and years from a school, an inspiring teacher and the prospects of a better life. But at least they’re too poor to be using tobacco.
Success in South America
This is not to say that children should not be protected from tobacco and any other products deemed to be suitable only for adults. And Brazil has seemingly done a good job in bringing in measures said by the WHO to encourage people not to start smoking or to quit if they have already done so, starting, according to the WHO report, from 1981 when the Ministry of Health set up the Commission for the Study of the Consequences of Tobacco. In 1999, Brazil also set up the National Commission on Tobacco Control to support the country’s role in negotiating the FCTC, which it signed in 2003 and ratified in 2005. And in 2018, Brazil also ratified the Protocol to Eliminate Illicit Trade in Tobacco Products.
Since 1989, Brazil has taken increasingly stringent steps against tobacco advertising and promotion and introduced bans on smoking in enclosed public places. The country has introduced increasingly graphic health warnings on tobacco packs and integrated cessation treatments into its public health system. And, of course, it has increased tobacco taxes, which, as of 2018, were said to represent 82.97 percent of the retail price of the most popular brand.
One of the more amazing—and rounded, it has to be said—figures to come out of Brazil’s efforts appears outside the special section on the country where, it is said, “when Brazil became the first large country to include its national quit line number in graphic health warnings on cigarette packaging, the quit line received unprecedented call volumes—reaching up to 6 million calls in the first year, and more than all other quit lines globally at that time.” Given that we live in a time of fake news, I should point out that “up to 6 million” could legitimately mean one. Just saying.
Whether due to these measures wholly or in part, adult smoking prevalence in Brazil was said by WHO to have declined from 35 percent in 1989 to 18.5 percent in 2008, the year the MPOWER measures were introduced, and to 14.7 percent in 2013. Adult cigarette smoking was said to have decreased in capital cities from 15.6 percent in 2007 to 10.1 percent in 2017.
But the smiling children didn’t do so well. “Despite declining smoking rates among adults, smoking prevalence among youth remains stable at around five percent, with 19 percent of boys and 17 percent of girls experimenting with smoking during their school years, according to PENSE [National Adolescent School-based Health Survey] 2015,” the report said.
Brazil is not the only country of South America featured prominently in the report. There is a piece on Colombia that describes how, from 2016 to 2017, tobacco taxes there have been increased hugely. But again, success is measured not against how many people quit smoking because of these increases but on the grounds that civil society groups were able to counteract the tobacco industry’s argument that tax increases would create an unmanageable surge in illicit trade and because Colombia managed “the highest level of achievement under the raise taxes on tobacco MPOWER measure.”
There was also a piece on Ecuador that focused on its integration of tobacco cessation strategies into its health system. But here, at least, we get a glimpse of what should be the focus of the WHO’s efforts: people quitting smoking. “From mid-March to mid-November 2018, 3,916 tobacco users were identified and given advice on quitting,” the report said. “Among the 2,069 patients who completed a follow-up at four months, the seven-day self-reported abstinence rate was 57.2 percent, and of the 968 who completed a six-month follow-up assessment, the self-reported abstinence rate was 48.9 percent.” So, my interpretation of these interventions suggests that just over 470 people are believed to have not smoked for a while. What can you possibly say? It’s a start?
Of course, it is impossible not to set Brazil’s success against the fact that the country is the biggest exporter of leaf tobacco. While Brazil is praised by the WHO for its MPOWERing, it is a major contributor to fueling what the WHO characterizes as the “global tobacco epidemic.” And this raises a number of questions.
Older readers will remember the arguments put forward in the past that EU farm subsidies should not go to supporting leaf tobacco growing, some of which had merit. But some cleaved to the ludicrous claim that if you stopped leaf production in the EU, you would stop smoking there, seemingly forgetting that the EU was a relatively small player in tobacco production and a major leaf importer. Brazil is not the EU, however. If Brazil stopped leaf production overnight, it would MPOWER the WHO’s activities like nothing else. And, of course, it would impoverish a lot of people, especially those in Brazil.
I would not advise such a course of action. As one reformed supporter of globalization once said, the basic responsibility of governments is to maximize the welfare of its citizens not to pursue some abstract concept of the global good.
But what is the WHO’s view? In its eyes, is impoverishment an acceptable side effect of curing the tobacco epidemic? Of course, I cannot know the answer to that question, but something tells me that it would be “yes.” If you look closely at the children whose pictures were chosen for publication by the WHO, most of them seem to be living in or close to poverty. I can assume only that, from the lofty heights of Geneva, Switzerland, poverty seems quite quaint.