The WHO and tobacco policy: a seven-point reform agenda
By Clive Bates
In the light of the global pandemic, there have been calls to abolish, repurpose or revitalize the World Health Organization. I am firmly in the revitalize camp. Naturally, most of the hindsight has focused on the WHO’s response to infectious diseases. In April 2021, Covid-19 deaths are approaching 3 million worldwide. However, according to the WHO, tobacco-related deaths exceed 8 million annually. So what would new thinking on the WHO’s approach to tobacco policy look like? Here is my seven-point reform plan.
1. Commit to the goals that make a real difference
The WHO is the lead agency for Sustainable Development Goal (SDG) 3—“Ensure healthy lives and promote well-being for all at all ages.” This broad goal is broken down into 13 targets, and SDG 3.4 is the target that really matters in tobacco policy:
“By 2030, reduce by one-third premature mortality from noncommunicable diseases through prevention and treatment and promote mental health and well-being [compared to 2015].”
This target should become the mission statement for the WHO’s work on tobacco. The WHO should have a laser focus on addressing severe disease—dying in agony of cancer, dropping dead with a heart attack, living in misery with emphysema—reducing real harms as far as possible as quickly as possible. It should not be distracted by dreams of a tobacco-free or nicotine-free society. It is possible to achieve radical reductions in disease burden by switching nicotine use from high-risk combustible tobacco products to low-risk smoke-free tobacco and nicotine products. This is the harm reduction strategy, and it provides a fast-acting way to reduce the drivers of disease among those most immediately at risk.
2. Embrace innovation in the tobacco and nicotine market
In theory, the WHO is open to innovation, and it recognizes that:
“Health innovation identifies new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health and well-being. Health innovation responds to unmet public health needs by creating new ways of thinking and working with a focus on the needs of vulnerable populations.”
This is a reasonable description of innovation in the technology and business models in the tobacco and nicotine market since 2007. No organization should be suckered by every new idea. Still, there is a pressing duty of curiosity and a moral obligation to see how innovations can be made to work for the greater good. Sadly, the WHO has been an enemy of innovation in this field, displaying indifference to significant opportunities while uncritically embracing prohibitionist or abstinence-only talking points and pseudoscience.
3. Implement harm reduction in the Framework Convention on Tobacco Control
If a reimagined WHO focuses on addressing the drivers of disease and embraces innovation, it follows that a rethink of the design of the Framework Convention on Tobacco Control is necessary. Fortunately, Article 1d of the FCTC defines tobacco control to include harm reduction:
“(d) ‘tobacco control’ means a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke.”
But making this concept operational means more than trivial tinkering. It means restructuring the treaty to be “risk proportionate.” That means taking a differentiated approach to different tobacco and nicotine products according to risk. The idea is to discourage the use of high-risk products while promoting migration to low-risk products. For example, taxes on cigarettes would be high but low or zero on vaping or heated-tobacco products. Advertising of cigarettes would be prohibited, but the promotion of low-risk products would be permitted but subject to controls on themes, placement and media type. Warnings would be stark, bold and pictorial on smoking products but would be more nuanced risk communication messages on smoke-free products, positioning them as lower risk than smoking but not risk free.
There is more to harm reduction than switching to reduced-risk products. A broad approach would address the whole spectrum of harms experienced by nicotine users. That includes harms induced by tobacco policy, including regressive taxes, stigma and intrusions into consumers’ autonomy to manage their own risks at their own expense and on their own initiative.
4. Take a more sophisticated approach to policy appraisal
Tobacco policymakers must make a realistic assessment of the impacts of their proposals, including the potential perverse consequences. The Royal College of Physicians captured the dangers very well in its 2016 report “Nicotine without smoke: Tobacco harm reduction”:
“However, if [a risk-averse, precautionary] approach also makes e-cigarettes less easily accessible, less palatable or acceptable, more expensive, less consumer-friendly or pharmacologically less effective, or inhibits innovation and development of new and improved products, then it causes harm by perpetuating smoking.”
This quite simple idea has yet to gain traction at the WHO. In January 2021, the WHO presented the findings of its expert panel on tobacco regulation to the WHO executive board. Recommendations include banning open vaping systems, banning all promotion of vaping products and treating heated-tobacco products like cigarettes in regulatory and fiscal terms. There is no sign that anyone involved considered how this could all go wrong and amount to regulatory protection of the cigarette trade, encourage smoking and cause more harm.
A revitalized WHO would become the global expert on both the intended and unintended consequences of tobacco policy and be respected for the quality of its policy analysis and guidance on impact assessment.
5. End the drive for prohibition
Outright prohibitions of low-risk products are a special case of bad policymaking. Through papers for the FCTC Conference of the Parties (for example, FCTC/COP/8/10) or decisions by the COP (for example, FCTC/COP8(22)), the WHO has used its influence to advocate prohibitions of low-risk products. The WHO’s prohibition reflex continues despite decades of evidence that nearly all prohibitions do more harm than good. Take the poster child of tobacco prohibition, the outright ban on tobacco in the Kingdom of Bhutan. Even the WHO has had to acknowledge it has been a dismal failure.
“Despite efforts on the part of relevant authorities, a tobacco black market, as initially feared, has emerged. Shops that thrive on illicit sale of tobacco and its products have found a way around the law. A steady stream of loyal customers continues to sustain these shops that have, over the years, grown into a network of black market. Recent studies have found Bhutanese youth, who are among the highest in the region to be using tobacco and its products, to be at the center of this burgeoning contraband good. (WHO Country Office for Bhutan 2020.)”
But that policy failure is compounded when the prohibition applies to much less risky products than the ubiquitously available market incumbent, cigarettes. Why would a health organization applaud India’s government for prohibiting e-cigarettes when India has around 100 million smokers? But the WHO celebrated with a tweet congratulating the country on its ban.
A revitalized WHO would not be a cheerleader for prohibition. It would play a dignified and diplomatic role, quietly counseling its members against policies that have known and obvious negative consequences.
6. Rethink the stakeholder landscape
Some critical stakeholders have been almost entirely excluded from the deliberations of the WHO and the FCTC. This has usually been justified on the spurious basis that they may be acting as agents of the tobacco industry. The most obvious omission is the consumer groups that represent the populations at risk and those likely to be directly affected by policies promoted by the WHO. They can rightly assert “nothing about us, without us” and refer to the inclusive philosophy of the Ottawa Charter on Health Promotion, yet they have no voice and are often treated with contempt.
The U.N. Framework Convention on Climate Change (UNFCCC) takes a more enlightened approach to stakeholders than the WHO FCTC. The FCTC restricts participation to international groups vetted and approved by the secretariat. It does not allow critical perspectives into its meetings. The UNFCCC, by contrast, welcomes anyone professionally engaged in the field, including climate change sceptics, the automotive trade and the coal industry, to register as observers even though their interests are not necessarily aligned with the objectives of the treaty.
7. Show some leadership
The FCTC was finalized in 2003, and it predates much of the innovation that underpins the harm reduction opportunity. But the problem is not merely with the text, which is a product of its time, but the culture of hostility to these innovations. Bad science and poor policymaking are pervasive in the WHO, the convention secretariat and among many delegates and advisers to the FCTC. The culture is further distorted by the flood of money from American philanthropic foundations with a prohibitionist agenda directly funding the WHO and many of the “civil society” groups that engage with the WHO. This culture will not change without a thorough reassessment at the highest leadership level or, if necessary, revitalized leadership. Too many lives are at stake to allow neglect and negligence at the WHO to deny hundreds of millions of people the opportunities of tobacco harm reduction.