Comment

Progress in beating the epidemic

1,2 Tobacco is a global health emergency. Tobacco use away from children. It is also incorrect to think that Published Online and second-hand smoke kill 8 million people each year heated-tobacco products are the answer, as they simply July 26, 2019 http://dx.doi.org/10.1016/ and leave many more in poor health; estimates suggest move tobacco users from one harmful tobacco product S0140-6736(19)31730-1 tobacco could kill up to 1 billion people this century.3 to another. Many tobacco users want to quit but do not have access To truly help tobacco users quit and to strengthen to cessation services. Proven tobacco cessation measures global , governments need to scale up include advice at primary care facilities, national toll-free policies and interventions that we know work. Tried and quit lines, behavioural tobacco cessation interventions tested interventions, such as nicotine and non-nicotine delivered through mobile phone text messaging pharmacotherapies, should be promoted for cessation. (mTobaccoCessation), and treatment with cost-covered The WHO report details the successes many countries tobacco cessation medications.4 are having in reducing tobacco use and strengthening The focus of the seventh WHO Report on the Global tobacco control strategies on key tobacco demand Tobacco Epidemic, 2019,5 published on July 26, reduction policies. Although the report has a particular reviewed progress in global efforts to introduce these focus on cessation, strategies addressed include evidence-based and comprehensive tobacco cessation monitoring tobacco use and prevention policies, interventions. The report shows how strong tobacco protecting people from tobacco smoke, warning about control policies, with a clear implementation strategy, the dangers of tobacco, enforcing bans on advertising, are being adopted around the world. 23 countries to promotion, and sponsorship, and raising taxes on date, representing 2·4 billion people, have adopted tobacco products. The report outlines what countries cessation support measures at best-practice level. need to do to further improve these efforts because we Much has been written and said about the potential know that millions of lives are saved through strong of electronic nicotine delivery systems (ENDS) such tobacco control measures.1,2 as e-cigarettes to help tobacco users quit.6–9 Although Enormous progress has been made in the fight against tobacco and related industries promote these products tobacco since the WHO Framework Convention on as tools for quitting, the evidence does not support their Tobacco Control (WHO FCTC) was adopted in 2003. For WHO Framework use as part of population-based cessation strategies. MPOWER (panel) has been a key tool that has helped Convention on Tobacco Control see https://www.who.int/fctc/en/ The aerosols of ENDS contain toxic chemicals that are countries implement measures to reduce demand for For MPOWER see https://www. harmful to both users and non-users and are, therefore, tobacco as required by the WHO FCTC and to protect who.int/tobacco/mpower/en/ products that come with health risks of their own.7,10 their populations from tobacco harms. And in combination with , which is the practice Worldwide, an estimated 5 billion people are now with the majority of ENDS users, the health effects of covered by at least one MPOWER measure, applied at the two or more products are combined.11 ENDS on their highest level of achievement as described in the WHO own are associated with increased risk of cardiovascular report.5 This is quadruple the number of people who were diseases12 and lung disorders13 and adverse effects covered by an MPOWER measure in 2007. on the development of the fetus during pregnancy.7 Of the six MPOWER measures, greatest growth in the For adolescents, the addictive nature of nicotine past 2 years has been in tobacco taxation with global can lead to dependence and may harm adolescent brain development, including reduced activity in the Panel: MPOWER tobacco control measures prefrontal cortex.14,15 Use of ENDS could also lead to a • Monitor tobacco use and prevention policies new generation of nicotine and tobacco users, as seen in • Protect people from tobacco smoke some countries,16 especially given how these products are • Offer help to quit tobacco use marketed to young people.7 Although the specific level of • Warn about the dangers of tobacco risk associated with ENDS has not yet been conclusively • Enforce bans on tobacco advertising, promotion, estimated, ENDS are undoubtedly harmful, should be and sponsorship • Raise taxes on tobacco strictly regulated, and, most importantly, must be kept

www.thelancet.com Published online July 26, 2019 http://dx.doi.org/10.1016/S0140-6736(19)31730-1 1 Comment

population coverage increasing from 8% in 2016 to 14% 4 Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions 5 for : an overview and network meta-analysis. in 2018. Although tobacco taxation is the most effective Cochrane Database Syst Rev 2013; 5: CD009329. way to reduce tobacco use, taxation is still the MPOWER 5 WHO. WHO report on the global tobacco epidemic, 2019. Geneva: World Health Organization, 2019. http://www.who.int/tobacco/global_ policy with the lowest global population coverage. report/en (accessed July 26, 2019). Tobacco taxation offers a win–win for governments by 6 WHO. Electronic nicotine delivery systems and/or electronic non nicotine delivery systems for cessation or reduction: a systematic protecting citizens from tobacco and raising revenues review and meta-analysis. Geneva: World Health Organization, 2016. that can be reinvested in health. 7 WHO. Electronic Nicotine Delivery Systems and Electronic Non-Nicotine Delivery Systems (ENDS/ENNDS). Report by WHO, Conference of the Parties Many countries have achieved the best practice level of to the WHO Framework Convention on Tobacco Control, Seventh session, FCTC/COP/7/11. 2016. https://www.who.int/fctc/cop/cop7/FCTC_ multiple MPOWER measures. But only two worldwide— COP_7_11_EN.pdf (accessed July 25, 2019). Brazil and Turkey—have adopted all MPOWER measures 8 National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: National Academies Press, at best-practice level. Too many countries still have weak 2018. tobacco control policies, as highlighted in the WHO 9 McNeill A, Brose LS, Calder R, Bauld L, Robson D. Vaping in England, an evidence update, February, 2019. A report commissioned by Public report, and a few have none at all. All countries have Health England. London: Public Health England, 2019. 10 WHO. Electronic nicotine delivery systems. Report by WHO, Conference of the ability and obligation to protect the health of their the Parties to the WHO Framework Convention on Tobacco Control, Sixth people by beating back the scourge of tobacco. session, FCTC/COP/6/10 Rev.1. 2014. https://apps.who.int/iris/ handle/10665/147110 (accessed July 25, 2019). 11 Wang JB, Olgin JE, Nah G, et al. Cigarette and e-cigarette dual use and risk of Tedros Adhanom Ghebreyesus cardiopulmonary symptoms in the Health eHeart Study. PLoS One 2018; 13: e0198681. World Health Organization, 1202 Geneva, Switzerland 12 Alzahrani T, Pena I, Temesgen N, Glantz SA. Association between electronic [email protected] cigarette use and myocardial infarction. Am J Prev Med 2018; 55: 455–61. I am the Director-General of WHO and declare no other competing interests. 13 Wills TA, Pagano I, Williams RJ, Tam EK. E-cigarette use and respiratory disorder in an adult sample. Drug Alcohol Depend 2019; 194: 363–70. © 2019. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights 14 England LJ, Aagaard K, Bloch M, et al. Developmental toxicity of nicotine: reserved. a transdisciplinary synthesis and implications for emerging tobacco 1 WHO. Tobacco. May 29, 2019. https://www.who.int/news-room/fact- products. Neurosci Biobehav Rev 2016; 72: 176–89. sheets/detail/tobacco (accessed July 24, 2019). 15 Morean ME, Krishnan-Sarin S, O’Malley SS. Assessing nicotine dependence 2 Henning K. Working together around the world to kick the big tobacco in adolescent e-cigarette users: the 4-item patient-reported outcomes habit. Health Aff Blog, Jan 5, 2017. https://www.healthaffairs.org/ measurement information system (PROMIS) nicotine dependence item do/10.1377/hblog20170105.058236/full/ (accessed July 24, 2019). bank for electronic cigarettes. Drug Alcohol Depend 2018; 188: 60–63. 3 Jha P, MacLennan M, Chaloupka FJ, et al. Global hazards of tobacco and the 16 Cullen KA, Ambrose BK, Gentzke AS, et al. Notes from the field: use of benefits of smoking cessation and tobacco taxes. In: Gelband H, Jha P, electronic cigarettes and any tobacco product among middle and high Sankaranarayanan R, et al, eds. Cancer: Disease Control Priorities, third school students—United States, 2011–2018. MMWR Morb Mortal Wkly Rep edition (volume 3). Washington, DC: The International Bank for 2018; 67: 1276–77. Reconstruction and Development, The World Bank, 2015: 175–94.

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