Wake-Up Call

Derek Yach

To speed up the demise of combustible cigarettes, the Framework Convention on Tobacco Control needs serious modifications, says Derek Yach.

By Stefanie Rossel

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) made headlines on its 15th anniversary in 2020. Unfortunately, the news was not that it was an overwhelming success but that progress toward getting rid of combustible tobacco was slow. Over the past two decades, overall global tobacco use has fallen, from 1.397 billion in 2000 to 1.337 billion in 2018, or by approximately 60 million people, according to the WHO. Eight million people still die every year from tobacco-related diseases. Critics warn that if the FCTC doesn’t modernize, a smoke-free world will remain a distant goal.

“The FCTC remains essentially frozen in time,” says global health expert and anti-smoking advocate Derek Yach, founder and president of the Foundation for a Smoke-Free World (FSFW). As a cabinet director and executive director of the WHO, Yach was instrumental in the development of the FCTC. “With the FCTC, which is a fairly ambitious document, we achieved our first goal to put tobacco use on a much higher footing within global health—and it has had its impact,” he continues. “In the late 1990s, global health meant infectious disease control to most people, and now it includes noninfectious diseases as well, such as heart disease, diabetes, cancer and mental health. Smoking prevalence has started to decline slowly in some parts of the world, although there are still countries where smoking rates are extremely high and rising.”

Eighty percent of the world’s smokers live in low-income and middle-income countries (LMICs). Applying the FCTC to these regions is the biggest challenge of the treaty, Yach says. “When looking at the single most impactful component of the framework convention—increased excise taxes—most LMICs have yet to even partially meet FCTC targets.

“I suspect this has to do with the universal problems of treaties. It’s nice to sit in Geneva and think about what laws will work in developing countries. If you take your examples from advanced industrialized countries instead of understanding the harsh realities of adapting regulations in poor countries where enforcement potential is low and political priorities are very different, things are a lot easier. In countries such as India or Indonesia or certain parts of Africa, we have not seen success, mainly because there’s weak legal enforcement on the tax side, a lot of corruption in the system and no political will or capacity to put smoke-free public policies in place. Some of the marketing bans have worked, but the tobacco industry continues to interfere with legislation in many countries, and this undermines anti-smoking laws.” Yach predicted that, even if the full range of FCTC recommendations was implemented, annual smoking-related deaths would still increase to 10 million by 2030.

Framework deficiencies

One challenge is that 17 of the FCTC’s signatories own significant shares in tobacco companies. These companies account for almost 50 percent of the global tobacco industry (see “The Contortionists,” Tobacco Reporter, January 2021). They tend to have a real conflict between their revenue and tax-raising needs, and a need to reduce the health effects of tobacco. Other shortcomings include the FCTC’s neglect of adult tobacco consumers who are trying to quit, which contributes to smoking rates staying high. “If you only focus on children not taking up smoking, you will see health benefits 50 years from now, but we want that impact in 15 [years] to 20 years,” Yach says. “For that to occur, better cessation strategies and the global rollout of harm reduction products are critical.”

FCTC recommendations that weakly impact tobacco use, such as health warnings on cigarette packs, have been widely introduced. Cessation assistance has not been promoted, and there is only slow implementation of the FCTC’s Articles 17 and 18, which stipulate the need to develop alternative livelihoods for tobacco farmers. Governments have also not been willing to hold the tobacco industry accountable for its actions, which is specified by the FCTC’s article 19.

Finally, promoting tobacco harm reduction (THR) products, which was part of tobacco control efforts in 2003 when the FCTC was drafted, remains undeveloped and currently only includes nicotine-replacement therapy (NRT). One reason for this is that governments remain deeply suspicious of tobacco industry claims that their new products will cut death and disease. Governments are also unwilling to seriously consider industry research, which they think is self-serving.

However, an examination of scientific output and patent filings shows that current research, regardless of the sponsor, is leading to new technologies capable of transforming the industry. “When we drafted the FCTC, we never anticipated this and as a result neglected the role of intellectual property rights,” says Yach. “At the time, we did not think something innovative and lifesaving could come out of tobacco companies, so why bother about intellectual property? How wrong we were!”

Filling the gaps

A nonprofit organization established in 2017, the FSFW aims to accelerate progress. The FSFW focuses on identifying and filling gaps in FCTC implementation and transforming the tobacco industry. It has developed a three-year strategic plan around three pillars—health, science and technology; agriculture and livelihoods; and industry transformation.

The FSFW’s approach and philosophy differ substantially from other philanthropies that support the FCTC. Yach pointed out that Bloomberg and the Gates Foundation support selected elements of the FCTC but actively back campaigns against THR products. “We’ve been very clear that we support provisions that children should never vape or smoke. However, our main objective is to help adult smokers quit by making cessation aids accessible and to support adult smokers switching to approved harm reduction products. These include snus, e-cigarettes, heated-tobacco products and nicotine pouches,” says Yach. “In the long term, tackling cessation together with harm reduction is the only way to bring smoking rates down relatively soon. If today’s adult smokers quit or switch, even into their fifties or sixties, they will see improvements in their quality of life.”

The FSFW strongly believes in investing in building research capacity in the nations in which it is doing research. No other major funders do this. “The health of a whole country improves when it has strong national scientific research capacity,” says Yach. “The scientists in a country become advocates for good policy in time, whereas keeping the money in the U.S., or doing all the work there and flying the experts in, undermines the development of tailored solutions that actually work.”

As the FSFW’s first strategic plan comes to an end, Yach says the Foundation is pretty much on target. “We have created a network of outstanding grantees who are producing work and scientific research that did not exist before, such as the second issue of the Global State of Tobacco Harm Reduction (GSTHR), which was released in November 2020.” (See “Uphill Struggle,” Tobacco Reporter, December 2020.)

In polls, the FSFW has tried to assess how important people’s perceptions of risk are to ending smoking. “We found out that knowledge of the risks of smoking is good in most countries but not in countries such as India or South Africa,” says Yach. “The intention to quit is often very high, but the resources available to [smokers] to do so successfully is often low. Access to NRT and reduced-risk products (RRPs) is almost zero in LMICs, yet we know that the countries doing best, such as the U.K. or Japan, are not just providing good cessation services and high-quality harm reduction alternatives, they are also helping smokers get access to these products, which is a big missing element in other countries. Our polls, however, show that more people now believe that nicotine causes cancer than they did two years ago. It does not. That view impedes smokers switching to reduced-risk tobacco products.”

Tools to drive change

The FSFW is supporting three institutions to drive change: the Center of Excellence for the Acceleration of Harm Reduction at the University of Catania in Italy; the Center of Research Excellence: Indigenous Sovereignty & Smoking in Auckland, New Zealand; and the Rose Research Center in North Carolina in the United States. Led by Jed Rose, co-inventor of the nicotine skin patch, the Rose Center is working on novel compounds and innovative treatments to improve the efficacy of smoking cessation therapy and harm reduction products.

The publication of the first Tobacco Transformation Index (see “Incentivizing Transformation,” Tobacco Reporter, April 2020) was another milestone. The index will help investors get a good idea of what tobacco companies are actually doing to address the health impacts of tobacco use, which will guide their investment policies. “For the investor, the question is where do I place my money to maximize my return and also maximize my impact on the environment and health,” says Yach. “We think the Tobacco Transformation Index is helpful guidance for them.”

The FSFW also has a hands-on approach to the FCTC goal of creating alternative livelihoods for tobacco farmers. It has set up the Center for Agricultural Transformation in Malawi, one of the most tobacco-dependent countries in the world. According to trendeconomy.com, unmanufactured tobacco accounted for $498 million, or 54 percent percent, of Malawi’s merchandise exports in 2019.

“Malawi has had a change in government, and the new administration is deeply committed to reducing dependence on tobacco,” Yach says. “We have signed a memorandum of understanding with the government and the National Planning Committee on accelerating alternatives and have created and supported the first National Policy Center that brings together government, industry, NGOs and academics. We support entrepreneurial agriculturalists, smallholder farmers and women. As a result, there have been new vegetable and dairy production projects as part of a broader portfolio. We see an upward movement, not only in agriculture, but in the economy.” The foundation is currently building a campus at Malawi’s major national agricultural university.

Challenging the COP9

The Foundation has many new research projects in the pipeline and will focus even more intensely on how change can be fast-tracked, how to counter misinformation on THR products and how to connect with doctors and health professionals in 2021, Yach says. Certainly the most important event this year is the Ninth Session of the Conference of the Parties to the FCTC (COP9), which had to be postponed until November of 2021 because of the Covid-19 pandemic. Article 28 of the FCTC addresses amendments to the convention. In a 2020 article published in Drugs and Alcohol Today, Yach provided a detailed agenda on how COP9 could modernize the FCTC, principally by a change in philosophy.

“I hope that the FCTC will align its policy to where the science is going, which would mean creating policies and actions that support harm reduction,” says Yach. “In addition, we seek progress on smoking cessation. It is long overdue that the COP discuss the pricing and availability of THR products in LMICs. I suspect many governments are likely to reverse their initial reactions to THR products based on emerging science and in response to the U.S. Food and Drug Administration’s decisions related to snus and IQOS. Historically, U.S. FDA decisions have been regarded as the gold standard of norm setting. That should be as true for THR products as it is for pharmaceuticals, vaccines and food.”

Yach is confident that even FCTC article 5.3, which excludes the tobacco industry and those it funds from the dialogue, might be overcome. The FSFW was immediately boycotted by the WHO because, even though the organization is independent, it receives funding from Philip Morris International Global Services. 

“The voices [against dialogue with the tobacco industry] are loudest from a very small group of people who grew up in tobacco control decades ago and got stuck in their careers with a very strong view,” says Yach. “However, there’s a new generation coming out of new areas of science and IT. They look at science in a different way than we did. They believe in private partnerships. They seek real change and not endless rhetoric. They are less interested in what the tobacco industry did decades ago than in what it can do today to save their mother or father.”

Because there is no internationally accepted research agenda on smoking reduction, there are significant research gaps in many countries and scientific fields, and most of them center around THR products. Yach thinks these products must be incorporated into the FCTC, and he indicated that the foundation is leading efforts to define research that could improve tobacco harm reduction in any way and guide and accelerate the end of smoking. Addressing these gaps will involve people in academia, regulatory bodies and industry. The list should be completed later this year.

“My view is that there will be an inevitable rise in the use of THR products and a decline in the use of combustible cigarettes. My hope is that we can speed that process up. If we do that, 3 million to 4 million tobacco-related deaths could be avoided every year over the next four decades. It’s worth pushing hard to achieve that goal.”