• April 20, 2024

Eyes on the Ball

 Eyes on the Ball
Image: Maksym Yemelyanov

Senior officials should approach COP10 with skepticism but not cynicism, with clarity about their national goals and with some tough questions about trade-offs, unintended consequences and evidence.

By Clive Bates

The tenth session of the Conference of the Parties (COP10) to the World Health Organization’s Framework Convention on Tobacco Control (FCTC) will take place in Panama from Nov. 20–25, 2023. Hundreds of representatives of the 182 parties and further hundreds of observers will descend on Panama to advance the global accord on tobacco control.

But how should an official government delegate prepare for and approach the meeting? As a former U.K. senior civil servant, I would like to offer some humble advice.

First, delegates should be clear on their national public health and tobacco policy goals. Governments could set a wide range of objectives: to reduce disease and death, reduce smoking, reduce tobacco use, prevent addiction, achieve a nicotine-free society, focus exclusively on youth prevention, protect nonsmokers or even destroy the tobacco industry.

Many delegates will be tempted to say, “All of the above.” That might have worked when the FCTC text was finalized in 2003, but it definitely does not work today. The reason is that there are now very significant trade-offs between these goals. For example, an effort to eliminate nicotine may mean fewer smokers switch to lower risk nicotine products, causing smoking to persist for longer and the burden of disease and death to be higher.

An exclusive focus on youth may mean considerable additional harm to adults given that adults who smoke are at the most immediate risk of serious disease and premature death. A delegate should arrive at the COP with a strong sense of what they want the FCTC to achieve. I believe the proper public health priority should be to reduce disease and death as deeply and rapidly as possible. Setting any other goal implies that a greater toll of disease and death would be justifiable to meet some other objective. The FCTC and COP should focus on making rapid health and welfare gains, especially among disadvantaged populations—every other goal should be subordinate to that one.

Second, delegates should approach the COP, the FCTC and the World Health Organization with considerable skepticism. Constructive skepticism will be the norm for many experienced officials, but the WHO does not welcome or expect this, especially from delegates from low-income and middle-income countries (LMICs). The WHO expects deference and to be regarded as an authority.

However, the WHO has not earned and does not deserve the unqualified trust of delegates from its member states. Let me give three reasons why delegates should be skeptical. One: The WHO cannot be trusted to make reliable, evidence-based policy recommendations. For example, the WHO promotes the prohibition of e-cigarettes and heated-tobacco products in situations where far more dangerous smoked tobacco products are freely available and widely consumed. It promotes prohibition without evidence that it will benefit public health, without concern that it will lead to more smoking and without any apparent grasp of the likelihood of illicit trade taking over from a law-abiding supply chain. Two: The WHO cannot be trusted to tell the truth about tobacco and nicotine products. The WHO’s fact sheet on e-cigarettes is full of errors and misinformation, and the agency is unwilling to correct the record or take a balanced view. Three: The WHO is not independent but financially and institutionally compromised by funding from special interest groups. The recently published WHO Report on the Global Tobacco Epidemic 2023, is a good example. The acknowledgements on page xvii show the report was funded by the private foundation of an American billionaire and written with the assistance of many activists funded by the same foundation. Michael Bloomberg’s foundation is a substantial funder of the WHO, and  Bloomberg has been appointed as a WHO Global Ambassador for Noncommunicable Diseases. Delegates should carefully consider this funding and its influence on the WHO’s approach. Bloomberg’s policy priorities may differ from those of parties to the FCTC.

Third, recognize that the so-called civil society representatives with observer status at the COP are not necessarily neutral guardians of the public interest. They are carefully selected activists, chosen for their allegiance to the WHO and almost always funded by foreign interests. Unlike other conventions, such as the United Nations Framework Convention on Climate Change, the FCTC is highly restrictive on which nongovernmental organizations (NGOs) are permitted as observers to the COP. Only 26 NGOs are currently accredited, and participating NGOs must be approved by the COP, provide evidence that they support the FCTC and show that they are working toward its implementation. A single NGO, now known as the Global Alliance for Tobacco Control, acts as an umbrella for smaller NGOs but only if they meet its membership criteria. The Secretariat assesses their suitability and reports to the COP.

This severe filter on who is eligible to participate has the effect and likely the intention of excluding any critics or skeptics or even diverse views of how to achieve public health goals through tobacco policy. The selective engagement of observers and NGOs creates an echo chamber and a significant bubble of groupthink in the COP. Through pressure and public shaming, the observers attempt to punish delegates who question orthodoxy or take a more pragmatic approach to the issues under discussion. Experienced diplomats will know they are not in Panama to please unrepresentative, unaccountable, opaquely funded interest groups that are often little more than obedient mouthpieces for foreign donors.

Fourth, take a hard look at the FCTC policy proposals under discussion at COP10. Through the advanced publication of COP documents, it is possible to see the intent of the WHO and the FCTC Secretariat reflected in the COP documents. Since it was finalized 20 years ago, the FCTC has drifted far from its original purpose: to contain and reduce the health and welfare harms primarily arising from smoking. The 2023 COP10 documents show that much of its energy is now devoted to fighting “harm reduction.” This is a legitimate public health strategy, aiming to capitalize on the rise of much safer ways to use nicotine than cigarette smoking, aiming to dramatically reduce the 8 million deaths annually attributable to smoking.

The problem with opposing harm reduction is that it is likely to cause harm increase. Hostile strategies for novel and emerging products are evident in the documentation. For example, an anonymously authored paper by the WHO for COP10 suggests three main strategies are in use: (i) falsely denying any health or reduced-risk benefits; (ii) treating low-risk products in the same way as high-risk products for the purposes of regulation; and (iii) positioning these products as no more than a tobacco industry survival strategy while ignoring the fact that such products have been deemed appropriate for the protection of public health by the U.S. Food and Drug Administration and that command considerable support in the public health community. Other documents reveal underhand tactics. For example, in a paper on definitions, the Secretariat tries to argue that the aerosols from vaping products should be classified as “smoke,” a scientifically baseless claim. But the purpose of this maneuver is to apply provisions in the FCTC that relate to “smoke” and “smoking” to products that do not involve combustion and are smoke-free. The problem with this approach is that, in practice, it will function to protect the cigarette trade from competition from much safer alternatives, implicitly promote smoking and cause more disease and death.

Fifth, ask the tough questions. As the physicist Richard Feynman said, “I would rather have questions that can’t be answered than answers that can’t be questioned.” That is a good way for delegates to approach COP10. Government officials should not be expected to have all the answers, but they should have the best questions. In the tobacco control field, four questions will help guide any delegate through the policy discussion. One: Who disagrees with this and why? Much of the research and evidence in this field is contested among independent experts. It is not just in dispute between the WHO and the tobacco industry. Delegates should be aware of and insist on seeing all sides of the debate. Two: What are the trade-offs? Are the needs of adult smokers being ignored? Have they considered the implications of anti-vaping measures on young people who would otherwise smoke? Three: What are the plausible unintended consequences? Will strict policies on vaping lead to increased smoking, the development of black markets or consumers starting to make their own do-it-yourself products? Four: Where is the evidence? The original idea of the FCTC was to help all countries adopt evidence-based tobacco policies that had been tried and tested. Now the WHO and the Secretariat want to use Article 2.1 of the FCTC to promote untried measures for which there is no supporting evidence.

I hope delegates find the COP10 meeting fruitful, but constructive skepticism from senior delegates will be healthy in the longer term and help to restore the FCTC’s credibility.