Global status of WHO FCTC implementation and the way forward on tobacco products taxes
The importance of the WHO Framework Convention on Tobacco Control
The tobacco industry and its affiliates exist to market death, disease and addiction to hundreds of millions of people around the world, particularly the youth. The industry survives only by maximising the number of people tricked into and trapped in addiction while working tirelessly to defeat, disrupt and distort the public-interest political and scientific processes that threaten to break the chains of addiction, protect the next generation and make the industry pay.
Countries that are Parties to the WHO Framework Convention on Tobacco Control (WHO FCTC) have together committed to a collective response that now covers over 90% of the world’s population. The WHO FCTC addresses the tobacco industry’s key health-harming practices with evidence-based measures, and overcomes the industry’s playbook of political and scientific interference through the consistent, effective bright-line rule established in Article 5.3 and its implementation guidelines. Up to 5.6 billion people — as much as 71% of the world population — are now protected by at least one of the WHO-recommended best-practice measures of the MPOWER technical package of highly-effective WHO FCTC demand-reduction interventions. All but three countries in the Eastern Mediterranean Region are covered by at least one best-practice MPOWER measure.
Nineteen years after its entry into force, the WHO FCTC remains an effective shield against the harms to health and governance posed by the fundamental and irreconcilable conflict between the tobacco industry’s interests and the public interest. It has turned the tide of the global tobacco use epidemic: prevalence has been decreasing steadily, and the number of tobacco users is projected to decline in the coming years.
Amid global progress there is a more uneven story at country level. The Eastern Mediterranean Region (EMR) contains 3 — Egypt, Jordan and Oman — of the only 6 countries worldwide in which tobacco use is still increasing. EMR also faces the additional challenge of uncertainty in calculating trends: only 88% of its population is covered by nationally representative population-based surveys, the least of any WHO region. Despite these challenges the region has seen a 20% relative reduction in tobacco use prevalence between 2010 and 2025.
That achievement is attributable to several critical actions taken by countries in the region: taxation increases, plain packaging, large graphic health warnings, cessation support, and bans and restrictions on tobacco advertising, promotion and sponsorship. Progress is, however, uneven across the Region, and the projected reduction will fall short of the 2025 target by only two percentage points — close enough that significantly scaling up and accelerating efforts could make a material difference to meeting the goals set by the WHO global action plan for the prevention and control of noncommunicable diseases 2013–2030 and the related Sustainable Development Goal target.
Overall, evidence shows that 24 million people aged ≤25 years and 2 million people aged 45–59 years have quit smoking during the first 10 years following ratification of the WHO FCTC. At least 12 million deaths can be estimated to have been averted by just one decade of WHO FCTC implementation. MPOWER has been estimated to have saved 300 million people from smoking over a 15-year period. Against the much slower progress on the broader targets of the NCD Global Action Plan, 94 countries are making significant progress in reducing tobacco use, and a smaller but still sizable group of 56 countries is on track to achieve the 30% relative reduction target. The contrast points to the decisive influence of the WHO FCTC in driving better health and health equity.
Despite this crucial progress, adoption and implementation of legislative and regulatory measures has occurred at a scale too small and a pace too slow to prevent over 8 million annual deaths, or to prevent millions more from being pulled into addiction each year. The WHO FCTC Conference of the Parties’ global strategy from its eighth meeting (COP 8) therefore calls for accelerating and sustaining momentum — adoption and implementation supported by the crucial enablers of consistent surveillance and full adherence to Article 5.3. What gets measured gets done, and governments that keep health-harming industries out of policymaking get ahead in public policy.
The commercial determinants of fiscal policy for health
The tobacco industry makes profit only because it does not pay the full price for its socially, environmentally and economically disastrous and unsustainable business model. For 2012 alone, the industry’s externalised costs were estimated at at least US$ 422 billion in global health expenditure and a further US$ 1.43 trillion+ in wider economic costs. A crucial public-health aim is to make the industry progressively account for the full cost of its deadly business. This was emphasised recently at COP 10, which called for implementation of Article 18 on the response to the devastating environmental impacts of the tobacco industry’s business, and for expert-led research on the establishment of liability regimes under Article 19 of the WHO FCTC.
Setting aside these novel measures, tobacco taxation remains the highly-effective, deeply-evidenced workhorse for ending the tobacco industry’s economically unsustainable business — by making it account for the costs it imposes on others and by impeding its use of pricing power to retain current users and funnel youth toward initiation. Modelling shows that a one-dollar tax increase across all countries in 2014 would have resulted in 66 million fewer smokers and 15 million fewer deaths, while raising an additional US$ 190 billion in revenue. Twenty-three countries that combined WHO FCTC ratification with substantial tax increases between 2008 and 2012 experienced at least two-fold greater decreases in both smoking initiation and smoking cessation compared with other WHO FCTC ratifying countries. On the same basis, there would have been 44 million fewer smokers aged ≤25 years had low-tax countries implemented similarly large tobacco tax increases.
Because of the scale of its negative externalities, the tobacco industry relies for its survival and growth on SCARE tactics to defeat and weaken measures — especially taxes — that would end the industry by making it account for the costs of its business model:
- S — Smuggling and illicit trade
- C — Court and legal challenges
- A — Anti-poor rhetoric
- R — Revenue reduction
- E — Employment impact
These false, misleading and exaggerated arguments are used as excuses to avoid taxation. As a result, tobacco tax policymaking remains vastly under-utilised: it is the least-implemented of the MPOWER measures, with only 12% of the world’s population protected to a best-practice level — an increase of only 5 percentage points between 2008 and 2022 and a decrease of 2 percentage points between 2020 and 2022. The situation in the EMR is similarly challenging. Only 3 of its 22 countries and territories — Jordan, Morocco and the State of Palestine — are at best-practice levels of tobacco taxation, and even among these, some (notably Jordan) need further progress on reducing affordability.
Sustaining progress on tobacco control and tobacco taxation
The evolving tactics of the tobacco industry — including its distorted “harm reduction” narrative and the attempted pharmaceuticalisation of its business model — pose significant challenges to sustaining progress on both tobacco control and taxation. These tactics are part of a broader “redemption narrative” aimed at rehabilitating the industry’s image, gaining access to policymakers and undermining the full and comprehensive application of tobacco control and tobacco tax measures.
The most prominent of these tactics is the industry’s engineering, design and targeted marketing of e-cigarettes to promote mass youth use, rather than their purported target market of middle-aged smokers unable to quit even with established cessation methods. This reemphasises both the exploitation and the political corruption at the heart of the tobacco industry’s business model. It also underlines that any purported “innovation” from the tobacco industry should not be taken at face value — as demonstrated by its extensive history of deception, exemplified by the filtered cigarette and the “light” and “low-tar” cigarette frauds on the public. The way the industry has appropriated the language of “harm reduction” must be repudiated as nothing more than a thin veil for a new fraud aimed at securing the next generation of nicotine addicts as potential customers for its conventional tobacco products.
The industry’s appropriation of “harm reduction” is also fundamentally contrary to the WHO FCTC. “Harm reduction” as defined in Article 1 must be read together with Article 5.2(a) — Parties acting with the aim of “preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke” — and the call in Article 5.3 to protect public-health policies from the commercial and vested interests of the tobacco industry. Discussions of harm reduction and the place of new products make sense only when cross-walked with the prevention of both individual- and population-level harms, and with steadfast adherence to Article 5.3.
These efforts are supported by the statement released by WHO in December 2023 on the regulation of novel products, which emphasises the need for urgent measures to prevent uptake and counter nicotine addiction as part of a comprehensive approach, and recommends strong regulation wherever countries permit the sale of such products — including the use of taxes. To respond to this new form of industry interference, WHO Member States (particularly Parties to the WHO FCTC) need to extend surveillance to these new products, to support the extension of tax treatment equivalent to that of conventional tobacco products, and to rebut industry deceptions and lies about e-cigarettes, adolescent burden and use patterns.
The way forward: addressing the commercial determinants
Looking forward, the response to tobacco industry interference needs to be oriented around the basic fact that, despite all its smoke and mirrors, the tobacco industry cannot “transform” itself out of the fundamental and irreconcilable conflict between its interests and the public interest. This was emphasised at the most recent Conference of the Parties to the WHO FCTC, where the Panama Declaration drew attention to these irreconcilable conflicts of interest and emphasised the corresponding need for policy coherence in implementing Article 5.3.
Across governments, at all levels and across sectors, Article 5.3 needs to remain the unambiguous lodestar for containing and preventing tobacco industry interference. With this as the anchor, the tobacco-transformation illusion will be penetrated and the industry revealed as merely using e-cigarettes and other new products as a Trojan horse to gain a seat at the policymaking table and legitimise itself as a credible partner.
While tobacco industry efforts to undermine Article 5.3 and obstruct tobacco taxation pose a major threat to progress on tobacco control, their success is not inevitable. They can be prevented with political will and reliance on the normative and technical guidance provided by the WHO FCTC and by WHO — particularly the WHO FCTC Conference of the Parties’ guidelines for implementing Article 6 and the guidance provided by the WHO technical manual on tobacco tax policy and administration.