WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2021 Addressing new and emerging products
fresh and alive Electronic Nicotine Delivery Systems (ENDS) are addictive and not without harm.
2 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 3 4 | WORLD HEALTH ORGANIZATION ENDS should be strictly regulated for maximum protection of public health.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 5 Children and adolescents who use ENDS can double their risk of smoking cigarettes.
6 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 7 m Monitor tobacco use and prevention policies p Protect people from tobacco smoke o Offer help to quit tobacco use w Warn about the dangers of tobacco e Enforce bans on tobacco advertising, promotion and sponsorship r Raise taxes on tobacco Tobacco control efforts must remain focused on reducing tobacco use and avoid distractions created by tobacco and related industries.
WHO report on the global tobacco epidemic, 2021: Addressing new and emerging products is the eighth in a series of WHO reports that tracks the status of the tobacco epidemic and interventions to combat it.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 9 WHO report on the global tobacco epidemic 2021: addressing new and emerging products ISBN 978-92-4-003209-5 (electronic version) ISBN 978-92-4-003210-1 (print version)
© World Health Organization 2021
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. WHO report on the global tobacco epidemic 2021: addressing new and emerging products. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by optimadesign.co.uk
10 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC, 2021 Addressing new and emerging products
Made possible by funding from Bloomberg Philanthropies CONTENTS
15 Foreword by Dr Tedros Adhanom Ghebreyesus, WHO Director-General 17 Foreword by Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases 19 Foreword by Dr Adriana Blanco Marquizo, Head of the WHO FCTC Secretariat
20 SUMMARY
24 THE WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL AND THE PROTOCOL TO ELIMINATE ILLICIT TRADE IN TOBACCO PRODUCTS
30 NEW AND EMERGING PRODUCTS
44 TOBACCO INDUSTRY INTERFERENCE
50 TOBACCO AND THE COVID-19 PANDEMIC
59 EFFECTIVE TOBACCO CONTROL MEASURES 60 Monitor tobacco use and prevention policies 64 Protect people from tobacco smoke 68 Offer help to quit tobacco use 72 Warn about the dangers of tobacco use 76 Anti-tobacco mass media campaigns 80 Enforce bans on tobacco advertising, promotion and sponsorship 86 Raise taxes on tobacco 94 National tobacco control programmes 98 Electronic nicotine delivery systems
108 CONCLUSION 110 REFERENCES
119 TECHNICAL NOTE I: Evaluation of existing policies and compliance 128 TECHNICAL NOTE II: Smoking prevalence in WHO Member States 130 TECHNICAL NOTE III: Tobacco taxes in WHO Member States
139 ANNEX I: Regional summary of MPOWER measures 153 ANNEX II: Electronic Nicotine Delivery Systems 179 ANNEX III: Year of highest level of achievement in selected tobacco control measures 193 ANNEX IV: Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world 199 ANNEX V: Status of the WHO Framework Convention on Tobacco Control and of the Protocol to Eliminate Illicit Trade in Tobacco Products
207 ACKNOWLEDGEMENTS
WEB ANNEX VI: Global tobacco control policy data WEB ANNEX VII: Country profiles WEB ANNEX VIII: Tobacco tax revenues WEB ANNEX IX: Tobacco taxes, prices and affordability WEB ANNEX X: Age-standardized prevalence estimates of tobacco use, 2019 WEB ANNEX XI: Country-provided prevalence data WEB ANNEX XII: Maps on global tobacco control policy data
Annexes VI to XII are available online at http://www.who.int/tobacco/global_report/en “Despite the challenges of the COVID-19 pandemic, over the past year many countries have persisted in advancing tobacco control as a key health priority.”
Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organization
14 | WORLD HEALTH ORGANIZATION 5.3 billion people are now covered by at least one MPOWER measure at the highest level of achievement
Since the last WHO report on the global This is encouraging progress. At the Political leaders must stand up to the tobacco epidemic in 2019, the world same time, we must remain vigilant to powerful vested interests that profit has changed immeasurably. Despite the the challenges posed by new products from tobacco. challenges of the COVID-19 pandemic, such as electronic nicotine delivery All countries have the obligation to over the past year many countries have systems and heated tobacco products. protect the health of their people by persisted in advancing tobacco control The WHO report on the global tobacco beating back the scourge of tobacco, as a key health priority. The progress epidemic 2021: addressing new whatever form it takes. presented in this report is testament to and emerging products highlights that perseverance. how these products are promoted Tobacco-attributable diseases include aggressively as “safer” or “smoke-free” lung and heart diseases, chronic alternatives to conventional cigarettes. respiratory diseases, cancers, and Although their full risks remain diabetes – all of which may increase unknown, the impact of nicotine the severity of COVID-19. Protecting delivery devices is clear. populations from the harms of tobacco While framing these products as a has never been more important. contribution to global tobacco control, The implementation of the WHO the tobacco and related industries Dr Tedros Adhanom Ghebreyesus Framework Convention on Tobacco employ the same old marketing Director-General Control is a recognized global tactics to promote new tools to hook World Health Organization development priority with a dedicated children on nicotine and circumvent target in the Sustainable Development tobacco legislation. At the same time, Goals. Reducing tobacco use is they continue to fight measures and critical to reducing the burden of legislation designed to protect people noncommunicable diseases, which from the many harms of tobacco across account for 71% of deaths globally. the globe.
Today, 75% of countries and 5.3 Tobacco is one of the world’s largest billion people are protected by at preventable causes of premature least one tobacco control measure at death, accounting for more than 8 best-practice level and 50% by at least million deaths and costing the global two measures. And globally, smoking economy US$ 1.4 trillion each year. prevalence among people aged over 15 This disproportionately affects people years has fallen from 22.7% to 17.5%. in low- and middle-income countries.
“We must remain vigilant to the challenges posed by new products such as electronic nicotine delivery systems and heated tobacco products.”
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 15 “Fighting tobacco use is truly a team effort, and as far as we have come, much more progress is still needed.”
Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases and Injuries Founder of Bloomberg Philanthropies
16 | WORLD HEALTH ORGANIZATION Despite a global pandemic, 24 countries have now adopted one or more best-practice MPOWER measures since the last report
Since the first WHO report on the measures in place to protect the public. This report brings a special focus to global tobacco epidemic was published Driven by the spread of MPOWER these new products and what we can 13 years ago, it has served as a tobacco control measures, global do to protect kids from them. Around critical resource in the fight to save cigarette sales began declining in 2012 80 countries have taken steps to lives from tobacco use. The data it and have continued ever since, even address the dangers of e-cigarettes, contains help leaders identify policies as the global population has grown. but they still remain unregulated in that work, and it helps the public to MPOWER measures have saved more much of the world. hold elected officials accountable than 37 million lives, a number that This report is a call to action and an for protecting people’s health. And increases every day, as more smokers outline for building on the progress while the last year has been marked quit, more people decide never to start we have made. Fighting tobacco use by more promising steps forward, using tobacco, and more of the public is truly a team effort, and as far as we the COVID-19 pandemic has also is protected from the deadly effects of have come, much more progress is still underlined the urgent need to do more, second-hand smoke. needed. Together, we can keep pushing faster, to end the tobacco epidemic. Today, 75% of all countries – that forward, and save many more lives. Evidence shows that cigarette smokers together are home to more than 5.3 are more likely to be hospitalized billion people – have at least one or die from COVID-19, a respiratory MPOWER measure in place. Half of all illness that attacks the lungs. The countries have two or more. Over the virus poses heightened risks to people past 2 years, despite the challenges with noncommunicable diseases like of the pandemic, five more countries heart disease, cancer, and high blood passed national smoke-free policies and pressure – all of which are associated eight more countries began requiring with smoking. health warnings on tobacco packaging.
Tobacco is the single biggest cause of But we are far from victory. More than Michael R. Bloomberg preventable death, killing 8.7 million 1 billion people around the world still WHO Global Ambassador for people each year and leading tens of smoke. And as cigarette sales have Noncommunicable Diseases and Injuries millions more to suffer from avoidable fallen, tobacco companies have been Founder, Bloomberg Philanthropies illnesses. The good news is: We know aggressively marketing new products how to tackle this killer. – like e-cigarettes and heated-tobacco products – and lobbying governments Since WHO launched the first report to limit their regulation. Their goal is 13 years ago, cigarette sales had been simple: to hook another generation on steadily climbing for decades, and nicotine. We cannot let that happen. in most of the world, there were no
“As cigarette sales have fallen, tobacco companies have been aggressively marketing new products – like e-cigarettes and heated-tobacco products – and lobby governments to limit their regulation. Their goal is simple: to hook another generation on nicotine. We cannot let that happen.”
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 17 “Tobacco control is an integral part of the development agenda, contributing not only to Sustainable Development Goal 3 (target 3.a calls for strengthening implementation of the WHO FCTC in all countries) but also to the achievement of other targets, directly or indirectly impacted by tobacco growth and use.”
Dr Adriana Blanco Marquizo, Head of the WHO FCTC Secretariat
18 | WORLD HEALTH ORGANIZATION In 2020 the WHO FCTC and the Protocol both increased the number of Parties
The Secretariat of the WHO Framework by COVID-19: these are often the as healthier alternatives to smoking Convention on Tobacco Control same people that the tobacco by their manufacturers (mainly the (WHO FCTC) and the Protocol to industry helped put into danger in tobacco industry) and their supporters. Eliminate Illicit Trade in Tobacco the first place. Smokers have worse Until independent research shows Products (Protocol) welcome the outcomes from COVID-19, as have the real risk profile of these products, publication of the WHO report on all people with noncommunicable governments should be cautious. the global tobacco epidemic, 2021. diseases, for which tobacco is a Science-based evidence, not marketing, common and major risk factor. should guide their actions. The report is published during one of the worst health emergencies in While the advances shown in the I call on governments who are party to history: the COVID-19 pandemic. report are encouraging, there is a the WHO FCTC and its Protocol to pull The pandemic has not only cost need to accelerate implementation together in their efforts to strengthen millions of lives globally, but has of the WHO FCTC and its Protocol. implementation, and to build a new profoundly affected economies, Tobacco control is an integral future for their populations, where exposed and exacerbated inequalities part of the development agenda, not only COVID-19 has been defeated, among and within countries, and contributing not only to Sustainable but also the harms caused by tobacco potentially reversed the gains made Development Goal 3 (Target 3.a calls use. There has never been a more by decades-long efforts to improve for strengthening implementation of pressing time to support populations human health and well-being, the WHO FCTC in all countries) but to quit tobacco use, and to raise taxes especially for vulnerable populations. also to the achievement of other on tobacco products – not only to targets, directly or indirectly impacted curb tobacco consumption, but also to The data provided in this report by tobacco growth and use. raise much-needed revenues to fund demonstrate some good news: a pandemic-recovery efforts. growing percentage of the world’s And while pandemics caused by population is now covered by at viruses are difficult to prevent, the least one or two fully implemented stealthy and ever-growing pandemic WHO FCTC measures, and in 2020 caused by tobacco is wholly and the WHO FCTC increased its number morally preventable. Unlike the of Parties to 182 and the Protocol COVID-19 pandemic, where scientists to 62. worked around the clock to find medicines to treat it and vaccines Unfortunately, the endless interference to prevent it, the solution for the of the tobacco industry has also grown. “tobacco pandemic” is in plain sight: During the COVID-19 pandemic, the WHO FCTC and its Protocol. Dr Adriana Blanco Marquizo industry (and those who work to Head of the WHO FCTC Secretariat further its interests) have increased Finally, new challenges lie ahead. their “corporate social responsibility” Electronic nicotine delivery systems efforts, offering to help governments – also known as e-cigarettes – and save the lives of those worst-affected novel tobacco products are promoted
“Until independent research shows the real risk profile of [ENDS], governments should be cautious. Science-based evidence, not marketing, should guide their actions.”
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 19 SUMMARY
Since the publication of the first WHO The number of countries adopting 45% of the world’s population to 56% report on the global tobacco epidemic MPOWER measures continues to rise in just 2 years. in 2008, the steady progress made by year-on-year. The number of countries Of the 49 countries that have not countries on tobacco control has been with at least one MPOWER measure yet adopted any MPOWER measure demonstrated in biennial updates, of in place has tripled since 2007 – from at the highest level, 38 have which this report is the latest. Despite 44 to 146 countries – and since the provisions in place that are just one the exceptional challenges brought on last WHO report on the global tobacco level below best-practice for one by the COVID-19 pandemic in 2020, epidemic, the number of countries with or more MPOWER measures. that progress continues. Latest results at least two MPOWER policies in place show that, as of 2020, more than 5.3 at the highest level of achievement Progress has been steady since the billion people – 69% of the world’s has increased from 84 to 98 (just last report, with seven countries that population – are covered by at least over half of all countries). In addition, previously had no best-practice measures one MPOWER measure at the highest the number of people now living in in place (Cook Islands, Côte d’Ivoire, level. Inspiringly, 98 countries are countries with at least two MPOWER Ethiopia, Iraq, Morocco, Paraguay, and now covered by at least two adopted measures in place rose from 3.5 billion Tonga) taking action to reach the highest MPOWER policies. in 2018 to 4.4 billion in 2020 – up from level on one or more measures.
Three quarters of countries and 5.3 billion people are now covered by at least one MPOWER measure at the highest level of achievement.
AT LEAST ONE MPOWER MEASURE AT HIGHEST LEVEL OF ACHIEVEMENT (2007–2020)
8 200 Total population: 7.8 billion Total number of countries: 195 7
146 6 139 150 124 5 5.3 107 5.1 4.9 4 93 100 76 3 56 2.9 Number of countries
Population protected (billions) Population 44 2.5 2 2.2 50 1.8 1 1.1
0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
20 | WORLD HEALTH ORGANIZATION
At least one MPOWER policy at highest level of achievement (2007–2020)
Total population: 7.8 billion Total number of countries: 195 8 200
7
6 139 146 150 124 5 5.3 5.1 107 4.9 4 93 100 76 3 56 2.9 Number of countries 44 2.5 50
Population protected (billions) Population 2 2.2 1.8 1 1.1 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries ENDS, leaving them particularly More than half the world ENDS need to be regulated vulnerable to the activities of the tobacco and related industries. is now covered by two This is the first time that the WHO MPOWER measures report on the global tobacco epidemic Using ENDS in public places where at the highest level of has included data on electronic nicotine smoking is banned may re-normalize achievement delivery systems (ENDS), and it reveals smoking in public. However, only that a total of 111 countries regulate 30 countries completely ban the use Of the 98 countries now covered ENDS in some way. Thirty two of these of ENDS in all indoor public places, by at least two measures, 31 have countries (covering 2.4 billion people) workplaces and public transport. three measures at the highest level ban the sale of ENDS, and the other 79 Only eight countries mandate the of achievement, and five countries countries have adopted one or more appearance of large graphic health have four measures at the highest legislative measures to regulate ENDS, warnings on ENDS packaging. level of achievement (Jordan, Ireland, covering 3.2 billion people. Twenty-two countries completely ban the advertising, promotion Madagascar, New Zealand, Spain). Of the countries that have banned and sponsorship of ENDS devices, Meanwhile, the number of countries the sale of ENDS, 18 are middle- e-liquids or both (only 15 countries that have adopted all MPOWER income countries, nine are high- have adopted advertising, sponsorship measures at best-practice level income countries and the remaining and promotion bans on both). remains at two, Brazil and Turkey. five are low-income countries. The current regulatory options taken by Monitoring ENDS use among children 79 countries include a wide range and adolescents, as well as adults, of measures with no common through nationally representative approach to address these products. surveys is increasingly conducted Eighty-four countries still have no globally. Eighty-seven countries have bans or regulations to address now collected data on the prevalence
AT LEAST TWO MPOWER MEASURES AT HIGHEST LEVEL OF ACHIEVEMENT (2007–2020)
8 200 Total population: 7.8 billion Total number of countries: 195 7
6 150
5 98
4 84 100 71 4.4 3 3.5 Number of countries 3.2
Population protected (billions) Population 46 2 37 50 26 1.4 1 11 15 1.1 0.9 0.5 0.5 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 21
At least two MPOWER policies at highest level of achievement (2007–2020)
Total population: 7.8 billion Total number of countries: 195 8 200
7
6 150
5
4 98 100 84 4.4 3 71 3.5 Number of countries 3.2 46 50
Population protected (billions) Population 2 37 26 1.4 1 15 11 0.9 1.1 0.5 0.5 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries 4.4 billion people, in 98 countries, are covered by at least two MPOWER measures at the highest level of achievement.
of ENDS use among adolescents and While cessation measures have made (from 8% in 2016 to 13% in 2018), the 56 countries have collected data on the progress during most years since 2007, proportion of the world’s population prevalence of ENDS use among adults. cessation service policies remain scarce, protected by taxes at best-practice level with only 26 countries providing these has since remained at 13%. Of the 86 countries where data services at best-practice level. Although are available on ENDS taxation, this measure is adopted by the fewest more than one-third do not impose countries, those countries nevertheless any excise tax on e-liquids. Where Countries in all regions contain 2.5 billion people, or one third taxes have been applied, tax rates of the world’s population, making it are adopting MPOWER are generally low, with only three the second most adopted MPOWER countries taxing ENDS e-liquids at measures measure in terms of population covered. 75% or more of the retail price. Each MPOWER measure has been Complete smoke-free indoor public Age restrictions to ENDS sale adopted at best-practice level by new places, workplaces and public transport and purchase are applied in only countries since the last report: now cover 1.8 billion people living in 67 42% of countries where ENDS countries, making it the second most ■ Five countries (Bolivia (Plurinational are not banned, and regulations adopted MPOWER measure in terms State of), Ethiopia, Jordan, Paraguay, applied on ENDS flavours can be of countries covered. Saint Lucia) newly adopted complete found in only nine countries. smoke-free laws covering all indoor Although tobacco advertising, public places, workplaces and public promotion and sponsorship (TAPS) transport. Progress in tobacco control bans remain an under-adopted measure, 1.6 billion people in ■ Five countries (Austria, Cook continues despite the global 57 countries are protected by Islands, Jordan, Philippines, Tonga) COVID-19 pandemic comprehensive bans on TAPS. Low- advanced to best-practice level with and middle-income countries have their tobacco use cessation services. Countries continued to make progress made particularly strong progress in However, during the same period, despite the COVID-19 pandemic. In TAPS bans. Twelve countries that have three other countries dropped from particular, health warning laws and adopted comprehensive TAPS the highest group, resulting in a net regulations at the highest level of bans are low-income countries gain of only two countries. achievement have now been adopted (41% of all low-income countries), ■ Eight countries (Ethiopia, Gambia, by 101 countries. This means that 4.7 31 are middle-income countries Mauritania, Montenegro, Niger, billion people (or 60% of the world’s (30% of middle-income countries) Nigeria, Qatar, United States of population) are now protected by large and 14 are high-income (23% America) adopted large graphic graphic pack warnings featuring all of high-income countries). pack warnings. recommended characteristics, making it the MPOWER measure with both Monitoring tobacco use, unfortunately, ■ Five countries (Côte d’Ivoire, the highest population coverage and was significantly affected by the Ethiopia, Iraq, Jordan, Venezuela the most countries covered. It is also COVID-19 pandemic. Data collection (Bolivarian Republic of)) important to note that by the end efforts were hindered in most countries introduced comprehensive of 2020, 17 countries had adopted during 2020, as was the release of bans on tobacco advertising, legislation mandating plain packaging results for surveys completed during promotion and sponsorship, of tobacco products and had issued 2018 and 2019. including at point-of-sale. regulations with implementation Raising prices through taxation is the ■ Six countries (Denmark, Georgia, deadlines. A handful of other countries most effective way to reduce tobacco Morocco, Netherlands, Portugal, Sri have required plain packaging by use and yet it remains the policy with Lanka) moved to the best-practice law but have not yet issued the the lowest population coverage. While group by levying taxes that comprise implementing rules. a large increase in population coverage at least 75% of retail prices. was observed between 2016 and 2018
22 | WORLD HEALTH ORGANIZATION THE STATE OF SELECTED TOBACCO CONTROL POLICIES IN THE WORLD, 2020
100% 100% 1 1 No known data, or 13 Data not no recent data or reported 32 40 90% 37 data that are not 90% 43 23 No policy or both recent and 56 weak policy representative 80% 80% Minimal Recent and 26 policies 70% representative 70% 23 103 51 data for either 49 Moderate adults or youth policies 60% 60% 43 Recent and 28 Complete representative 98 policies 50% data for both 50% 29 adults and youth 110 40% 40% 29 13 Refer to Technical Recent, 69 Note I for category representative definitions. 30% and periodic 30% 33 Proportion of countries data for both Proportion of countries 101 Note: Brunei Darussalam
(Number of countries inside bars) adults and youth (Number of countries inside bars) is excluded from R 20% 78 20% 67 because no retail sale of Refer to Technical Note I 57 cigarettes or renewal of 10% for category definitions. 10% 26 45 40 cigarette import licenses have been reported 0% 0% since May 2014. M P O W E R Monitoring Smoke-free Cessation Pack Mass Advertising Taxation environments programmes warnings media bans
INCREASE IN THE WORLD POPULATION COVERED BY SELECTED TOBACCO CONTROL POLICIES, 2007* TO 2020
100% * 2010 for W Mass Media, 2008 for R Taxation
90%
80% 2020 2007 70%
60% 55% 38% 50%
40% 11%
30% Share of world population 27% 32% 20% 21% 19% 19% 10% 6% 7% 0% 3% 5% 5% 3% M P O W E R Monitoring Smoke-free Cessation Pack Mass Advertising Taxation environments programmes warnings media bans
There are 49 countries that have yet to adopt a single MPOWER measure at the highest level of achievement.
burden caused by tobacco use and Furthermore, the pace of progress Some countries have exposure to second-hand smoke. Yet, of certain MPOWER measures is yet to adopt a single in 2020, 49 countries had not yet slower than others. The adoption MPOWER measure adopted a single MPOWER measure at of complete TAPS bans, the best-practice level, leaving 2.4 billion adoption of comprehensive All countries can adopt and implement people vulnerable to the tobacco cessation services and the raising comprehensive tobacco control industry’s tactics and marketing. of tobacco taxes to sufficiently measures to prevent the immense high levels must be accelerated.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 23 THE WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL AND THE PROTOCOL TO ELIMINATE ILLICIT TRADE IN TOBACCO PRODUCTS
The Convention also contains general and finely tuned set of obligations. Introduction to the WHO obligations that are crucial to these Illicit trade in tobacco products poses FCTC and the Protocol demand- and supply-reduction a significant threat to key demand- measures (and especially those in the reduction measures, in particular price The WHO Framework Convention on MPOWER package). Article 5 provides measures and health warnings. Tobacco Control (WHO FCTC) is an the basis for the governance of The Protocol came into force in evidence-based treaty that reaffirms tobacco control, with Paragraph 1 and September 2018 and currently counts the right of all people to the highest Paragraph 2 calling for a multisectoral, 63 Parties as of 25 May 2021. It aims standard of health. Adopted in 2003 whole-of-government approach at the elimination of all forms of by WHO Member States, it provides a and the development of appropriate illicit trade in tobacco products and framework for tobacco control measures national legislation and strategies. its obligations encompass tools for to be implemented by its Parties in order Paragraph 3 of Article 5, together with preventing illicit trade, and numerous to reduce continually and substantially the guidelines for implementation of mechanisms for promoting cooperation the prevalence of tobacco use and the Article 5.3, provides the basis between countries. Parties to the exposure to tobacco smoke. It is among for protecting tobacco control public Protocol assume substantive obligations the most widely embraced treaties in health policies from the influence of to: control the supply chain for tobacco the UN’s history, with 182 Parties that the tobacco industry and those who products; make it an offence to have together comprise more than 90% of work to further its interest. Those any involvement with illicit trade; and the world’s population. Since its entry measures, together with Article 19 cooperate with other countries in the into force in 2005, the WHO FCTC has on tobacco industry liability, make the prevention of illicit trade. The Protocol been an unambiguous success and Convention innovative in its ability to also has its own governing body, the remains the organizing principle for target an industry known for using Meeting of the Parties (MOP), which, progress and cooperation on tobacco deceptive means to prioritize profits like the COP, convenes biennially. control locally, nationally, regionally, over public health. and globally. The WHO FCTC also mandated the COP The WHO FCTC governing body, the to establish a Convention Secretariat In becoming a Party to the WHO biennial Conference of the Parties to provide policy support to Parties FCTC, countries assume mutually (COP), is the leading global forum for in implementing the Convention, as reinforcing obligations to reduce discussing and reaching consensus well as to support the functioning of the demand for, and supply of, on Convention implementation and the COP and other subsidiary body tobacco products. The MPOWER any emerging tobacco control issues, meetings. The Protocol established technical package – developed by and is the sole body for authoritative that the Convention Secretariat is also WHO – helps countries implement interpretations of the Convention’s its Secretariat, with similar functions. most of these demand-reduction provisions. In 2012, at the Fifth Session WHO cooperates with the Convention measures by providing a measurable of the COP in the Republic of Korea, Secretariat to support Parties to the gold standard for their achievement Parties adopted a new international WHO FCTC and to the Protocol in their and monitoring progress towards treaty: the Protocol to Eliminate Illicit substantive and reporting requirements, it. While the MPOWER package’s Trade in Tobacco Products. The Protocol and also advocates to increase the cost-effectiveness justifies this focus, builds on Article 15 of the Convention number of Parties to the WHO FCTC supply-reduction measures are also that addresses illicit trade in tobacco and the Protocol. needed for a comprehensive, synergistic products, but the complexity of approach and for supporting the transboundary cooperation to prevent political economy of tobacco control. illicit trade required a more extensive
24 | WORLD HEALTH ORGANIZATION KEY WHO FCTC PROVISIONS
Demand-reduction Article 6: Price and tax measures to reduce the demand for tobacco measures Article 8: Protection from exposure to tobacco smoke Article 9: Regulation of the contents of tobacco products Article 10: Regulation of tobacco product disclosures Article 11: Packaging and labelling of tobacco products Article 12: Education, communication, training and public awareness Article 13: Tobacco advertising, promotion and sponsorship Article 14: Demand-reduction measures concerning tobacco dependence and cessation
Supply-reduction Article 15: Illicit trade in tobacco products measures Article 16: Sales to and by minors Article 17: Provision of support for economically viable alternative activities
General obligations Article 4: Guiding principles Article 5: General obligations
■ 5.1: Comprehensive multisectoral national tobacco control strategies, plans and programmes ■ 5.2: National coordinating mechanism or tobacco control focal point ■ 5.3: Protecting tobacco control policies from the tobacco industry’s commercial and vested interests
Other measures Article 18: Protection of the environment and the health of persons Article 19: Liability Article 20: Research, surveillance and exchange of information Article 21: Reporting and exchange of information Article 22: Cooperation in the scientific, technical and legal fields and provisions of related expertise
The Conference of the Parties has provided guidance on the regulation of novel and emerging tobacco products and nicotine products since 2008.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 25 revenue to fight the pandemic and its from a subsidiary body established by COVID-19’s effect on associated economic crisis. MOP1 on tracking and tracing systems for tobacco products. Under Article WHO FCTC / Protocol The tobacco industry has taken 8 of the Protocol, Parties agreed to Implementation advantage of the situation by muddying establish a global tracking and tracing the science on tobacco’s link with regime by September 2023. This global The devastation caused by the COVID-19 COVID-19 and positioning itself as an regime will comprise national and pandemic starkly illustrates the need for economic and development partner regional systems intended to ensure accelerated implementation of the WHO for national COVID-19 recovery efforts. that Parties can secure the supply FCTC and the Protocol, with a particular Many of the major tobacco industry chain of tobacco products, and a focus on scaling up achievement using actors have – under the banner of global information-sharing focal point the MPOWER technical package. There is so-called corporate social responsibility located at the Convention Secretariat irrefutable evidence of a deadly interplay – used a small portion of their immense that will enable Parties to exchange between COVID-19 and tobacco use, resources on heavily publicized COVID- information in order to better tackle both past and present: those infected 19-related charity programmes. As illicit trade. The MOP’s deliberation on with the virus and who are tobacco the Guidelines for implementation of this matter will be crucial for guiding users have suffered more severe disease Article 13 of the WHO FCTC note, these and promoting timely implementation progression than non-tobacco users; activities are a form of sponsorship. the vulnerability of health systems has of this technically complex obligation. been exacerbated; and tobacco use has increased the pandemic’s human and economic costs (1–6). Accordingly, The COP9 (8–13 November 2021) Novel and emerging global and national efforts to build back and MOP2 (15–18 November 2021) tobacco products and better will be incomplete unless the “tobacco pandemic”, alongside other The COVID-19 pandemic means that nicotine products vulnerabilities underlying the crisis, the forthcoming sessions of the COP The COP has provided guidance on are addressed. and MOP will be held virtually. At the regulation of novel and emerging the sessions, delegates will note the More broadly, the COVID-19 pandemic tobacco products and nicotine products implementation progress attained and accompanying global economic since 2008, with a particular focus and identify challenges and possible recession have disrupted political on heated tobacco products (HTPs), opportunities for advancing and agendas. This has, in certain cases, electronic nicotine delivery systems strengthening the comprehensive come at the expense of activities such (ENDS) and electronic non-nicotine implementation of the respective as tobacco control, that may appear delivery systems (ENNDS) (7). The treaties. Parties will adopt new less pressing or uneconomical. This has COP has defined the landscape as decisions to guide the future direction challenged progress on implementation follows. HTPs are tobacco products, of implementation for both treaties by, of the WHO FCTC and the Protocol. which produce aerosols containing inter alia, establishing new subsidiary Most strikingly, the Ninth Session of the nicotine and other chemicals, by bodies, clarifying the interpretation COP (COP9) and the Second Session of heating tobacco units; they are subject of obligations and requesting the the MOP (MOP2), originally scheduled to the provisions of the WHO FCTC. Convention Secretariat and/or inviting for November 2020, were postponed By contrast, ENDS and ENNDS do not WHO to undertake some tasks and until November 2021. contain tobacco and instead vaporize report on specific matters. a solution composed of numerous But the COVID-19 pandemic has also After nearly 2 years of pandemic- compounds, which include nicotine provided opportunities for advancing related disruption to the tobacco in the case of ENDS, or may not tobacco control measures. For control agenda and despite an abridged contain nicotine in the case of ENNDS. example, 17 countries in the Eastern Provisional Agenda, both COP9 and Regarding the latter products, COP6 Mediterranean Region have banned the MOP2 will feature important items invited Parties “to consider prohibiting use of waterpipes (shishas) in public for consideration, such as a proposed or regulating ENDS/ENNDS, including as places, and South Africa temporarily investment fund for the WHO FCTC tobacco products, medicinal products, banned tobacco sales under a general and the Protocol – an innovative consumer products, or other categories, ban on the sale of “non-essential” financing mechanism that aims to as appropriate, taking into account products during the country’s pandemic provide much-needed resources for a high level of protection for human response. Similarly, other countries the implementation of both treaties. health”(8). At COP7, Parties were also such as South Africa and the Russian invited to apply regulatory measures Federation have raised tobacco taxes in A highlight of the MOP2 Provisional to prohibit or restrict the manufacture, an effort to save lives while mobilizing Agenda is the consideration of a report import, distribution, presentation,
26 | WORLD HEALTH ORGANIZATION sale and use of ENDS/ENNDS, as that Parties were invited to pursue This was followed, in 2016, by a appropriate (9). As noted in a WHO when addressing ENDS/ENNDS, COP7 decision inviting Parties to report submitted to COP8, the tobacco including: (a) preventing initiation by consider prohibiting or restricting the industry’s promotion of products in non-smokers and youth with special manufacture, import, distribution, each category can be considered a attention to vulnerable groups; (b) presentation, sale and use of ENDS/ response to declining sales of cigarettes minimizing as far as possible potential ENNDS, as appropriate to their national in high-income countries (10). health risks to users and protecting laws and public health objectives. Parties non-users from exposure to emissions; that have not totally banned those Work on addressing ENDS (c) preventing unproven health claims products were invited to follow a non- at the COP to date being made about ENDS/ENNDS; exhaustive list of regulatory options for At COP3, the Convention Secretariat and (d) protecting tobacco-control pursuing the objectives set out in the was requested to invite WHO to submit activities from all commercial and COP6 decision – provided in a report a report to COP4, identifying best other vested interests related to these prepared by WHO – that were endorsed practices in reporting to regulators products, including interests of the for consideration by the Parties (8). Such on the contents, emissions, and tobacco industry. Parties were also regulation entails the application of most product characteristics, including for invited to consider prohibiting or of the WHO FCTC demand and supply electronic systems. Since then, multiple regulating ENDS/ENNDS, including as reduction measures to ENDS/ENNDS, reports and decisions have addressed tobacco products, medicinal products, as well as the concerted application of the matter. consumer products, or other categories Article 5.3 (11). as appropriate, taking into account The most relevant decisions are from a high level of protection for human COP6, which set out basic objectives health (8).
TIMELINE OF ENDS-RELATED DECISIONS AT, AND REPORT TO, THE COP
Decisions by the COP Reports to the COP
COP4 FCTC / COP4 FCTC / COP4 2010 (14) /12 COP The Secretariat and WHO Secretariat Emerging regulatory gap are requested to report on on ENDS identified Decision Parties experience of ENDS Report COP5 FCTC / COP5 FCTC / COP5 2012 (10) /13 WHO is invited to identity The Secretariat and COP options for controlling Secretariat WHO identify Decision ENDS and examine the Report divergence in regulatory evidence-base on harms approaches to ENDS COP6 FCTC / COP6 FCTC / COP6 /10 (9) Rev.1 2014 Parties are invited to pursue WHO sets out regulatory certain objectives in their options and describes the COP regulation of ENDS such as WHO evidence on ENDS as weak Decision preventing initiation, minimizing Report and characterized by health risks and preventing uncertain as to their risk to COP7 FCTC / COP7 second-hand exposure FCTC / COP7 health and cessation potential (9) /11 2016 COP endorses the policy options WHO emphasizes the threat set out in the WHO report and to health and tobacco control COP invites the Parties to consider WHO posed by ENDS and sets out Decision applying these measures to Report a non-exhaustive list of prohibit or restrict presentation, options for pursuing the COP8 sale and use of ENDS FCTC/COP objectives detailed by COP-6 2018 /8/10 Progress report on the Secretariat ENDS regulatory measures Report undertaken by Parties
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 27 Work on addressing HTPs 13 of the WHO FCTC; (e) regulating Contextualizing the WHO at the COP to date the contents and the disclosure of report on the global tobacco the contents of these products in Since their emergence, HTPs have been epidemic, 2021 accordance with Articles 9 and 10 marketed with health and cessation The focus of this report – addressing of the WHO FCTC; (f) protecting claims that are not supported by new and emerging products – is tobacco-control policies and activities independent, solid evidence (12). important at a time when the tobacco from all commercial and other vested Cessation is defined in the Guidelines industry is using new strategies to interests related to these products, for implementation of Article 14 of the position itself as a development partner. including interests of the tobacco WHO FCTC as “the process of stopping The foundation for the regulation of industry, in accordance with Article the use of any tobacco product…” ENDS and HTPs, laid down by the COP, 5.3 of the WHO FCTC; (g) regulating – and it is, therefore, implausible to has been crucial for translating technical including restriction or prohibition, as claim this may be done by switching recommendations into political action appropriate – the manufacture, import, to another tobacco product. In 2016, at the national level. distribution, presentation, sale and the COP7 requested the Convention use of these products, as appropriate The documents analysed in this chapter Secretariat to invite WHO to report on to their national laws, taking into are the political decisions made by specific questions related to HTPs at the account a high level of protection for Parties to the WHO FCTC in relation to subsequent session (13). human health; (h) applying, where the regulation of ENDS and HTPs. Until Following this report, in 2018, COP8 appropriate, the above measures to solid and independent science present defined HTPs as tobacco products, and the devices designed for consuming a different scenario for consideration of “therefore subject to the provisions such products (9). the Parties, these provide the regulatory of the WHO FCTC”. Parties were options that Parties to the WHO FCTC In 2018 the Convention Secretariat, invited to prioritize certain measures are invited to follow. WHO, and the WHO Tobacco in addressing the challenges posed Laboratory Network were also invited They are markers of global sentiment by novel and emerging tobacco by the COP to report on various capable of cutting through the products such as HTPs, and the characteristics of novel and emerging commercially interested noise and devices designed for consuming such tobacco products, in particular tobacco industry obfuscation that products. Such measures included: HTPs, as well as to monitor market surrounds these products. Such (a) preventing initiation into use developments and the use of these decisions are influential in national of novel and emerging tobacco products. Despite HTPs unambiguously regulation and can also contain legally products; (b) protecting people being tobacco products, some of their authoritative interpretations from exposure to their emissions product characteristics pose regulatory of the WHO FCTC’s provisions. and explicitly extending the scope challenges for their definition and of smoke-free legislation to these classification, as well as for the products in accordance with Article comprehensive application of the 8 of the WHO FCTC; (c) preventing WHO FCTC. For that reason, the COP health claims from being made requested the Convention Secretariat about these products; (d) applying and invited WHO to provide more measures regarding the advertising, information on novel tobacco products, promotion and sponsorship of these in particular HTPs, to COP9 (9). products in accordance with Article
In 2018, COP8 defined heated tobacco products as tobacco products, and are therefore subject to the provisions of the WHO FCTC.
28 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 29 NEW AND EMERGING PRODUCTS: ADDRESSING ELECTRONIC NICOTINE DELIVERY SYSTEMS
Global tobacco control efforts have made significant strides in reducing tobacco use and ensuring people in many parts of the world are protected from the harms of tobacco. However, in recent years, newer and emerging nicotine and tobacco products, like electronic nicotine delivery systems (ENDS), have proliferated in many markets. While the tobacco industry implies that ENDS are safer because they do not contain tobacco, ENDS continue to grow the industry’s customer base, including through attracting younger users.
Some of the nicotine and tobacco the same as ENDS but the e-liquids used that was formulated as nicotine-free. products fast emerging in different are marketed as nicotine-free. Therefore, it can be almost impossible to markets – including ENDS, heated distinguish between ENDS and ENNDS. The most common ENDS are tobacco products (HTPs) and nicotine “electronic cigarettes”, also known as Even where ENNDS are nicotine-free pouches – pose serious health “e-cigarettes”, “vapes”, or “vape pens”. there are other concerns related to the concerns. HTPs have been recognized Other categories of ENDS include e-liquid they use, which contains harmful by the eighth conference of the parties “e-hookahs”, “e-pipes” and “e-cigars”. and potentially harmful constituents, to the WHO FCTC as tobacco products Some of the products resemble their which when inhaled may have long-term and should be subject to the provisions conventional tobacco counterparts; health impacts (15). In addition, as with of the WHO FCTC. They will therefore others are shaped like pens, USB ENDS, the act of using ENNDS mimics not be addressed in detail in the report. memory sticks, or basic cylinders. the use of conventional cigarettes, which This report focuses mainly on electronic is a behavioural pattern that can prevent delivery systems, and the increasingly Why electronic non-nicotine those trying to quit tobacco from prominent role they play in the delivery systems ENNDS are doing so successfully – and it may even strategies of the tobacco and related included in this report contribute to non-smokers (particularly industries.1 ENNDS can be almost indistinguishable children and adolescents) taking up the use of conventional cigarettes. What are electronic from ENDS: they often have enhanced For policy-makers, the presence and delivery systems? flavours that appeal to young people and are often perceived as “safer” and availability of a non-nicotine electronic For the purposes of this report, there are non-addictive. However, while ENNDS, delivery system further complicates and two types of electronic delivery systems: by definition, should not contain confuses regulatory mechanisms that ENDS and ENNDS. These systems heat a nicotine, in practice many e-liquids are intended to protect people from liquid to create aerosols that are inhaled marked as containing “zero-nicotine” the harms of tobacco and nicotine, by the user. These “e-liquids” may have been found to contain nicotine potentially generating loopholes that can or may not contain nicotine (but not when tested (14). Further, depending be exploited by commercial interests. tobacco)2 and other additives, flavours on the device used, the user can choose and chemicals that can be toxic to For all the reasons above, ENNDS e-liquids that either contain nicotine or people’s health. ENNDS are essentially should be regulated and monitored not, and can add nicotine to an e-liquid in the same way as ENDS.
1 “Industries” here refers to the tobacco industry, ENDS manufacturers, and any organizational body with commercial interests in ENDS or ENNDS. 2 Most ENDS use nicotine derived from tobacco, which leads some countries, including the United States, to classify them as tobacco products.
30 | WORLD HEALTH ORGANIZATION New and emerging products should be included in a comprehensive approach to tobacco control
The rationale for addressing ENDS as part of tobacco control strategies includes the following:
■ Article 5.2 of the WHO FCTC ■ ENDS are harmful. For example, ■ The tobacco and related industries obliges Parties to implement nicotine can have deleterious and ENDS advocates have tried to effective measures aimed at impacts on brain development, undermine indoor smoking bans preventing and reducing tobacco leading to long-term consequences by lobbying for an exception for consumption, nicotine addiction for children and adolescents in the use of ENDS. ENDS generate and exposure to tobacco smoke, particular (15). an aerosol that looks similar to and decision FCTC/COP7(9) tobacco smoke – an association ■ ENDS are marketed in thousands invites Parties to consider applying further complicated by the difficulty of flavours, which can increase the regulatory measures (such as those in distinguishing these devices palatability of the product and help referred to in document FCTC/ from HTPs, which, like cigarettes, them be targeted specifically at COP/7/11) to prohibit or restrict the contain tobacco. Therefore, it is children and young adults. manufacture, import, distribution, often difficult to tell if a person is presentation, sale and use of ENDS, smoking a tobacco product or using ■ In many social contexts, smoking as appropriate to their national laws tobacco has been “denormalized”, an ENDS. and public health objectives. particularly in indoor public areas. ■ ENDS are marketed and promoted by ■ ENDS contain nicotine, which is The use of ENDS mimics the hand the tobacco and related industries, the highly addictive component to mouth action associated with employing many established tactics of tobacco. Using ENDS poses the conventional smoked tobacco (see “Tobacco industry interference” risk of nicotine addiction, including products. The use of ENDS, chapter) to target their products at among children and adolescents. therefore, may risk renormalizing young people. Research findings show that ENDS smoking behaviour, particularly users are more likely to become among younger populations (17–19). cigarette smokers, exposing them to the harmful effects of smoking (16).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 31 ENDS were first developed by sales in 2018 was less than 2.2% of the continuously being developed. There companies independent of the total market value, while cigarette sales is also a variety of “generations” tobacco industry, but tobacco alone accounted for 91% of the same of ENDS that differ according to manufacturers have since total market value (22). Consumers technology and how they are designed entered the ENDS market in Western European and other to be used. countries (including the United States The early growth of the ENDS market Open systems have refillable tanks of America (the United States) and was driven largely by companies and can be modified, whereas Canada) comprise the largest portion independent of traditional tobacco closed systems are not meant to be of this market, followed by those in companies, such as Pax Labs which modified and use pre-filled cartridges Asia-Pacific countries. According to developed the Juul e-cigarette. or pods, or come pre-filled, as in the 2015–2018 data and projections, ENDS However, almost all major multinational case of disposable ENDS. Over time, use is expected to recover from a brief tobacco companies, such as British developments have included increasing period of decline (2019–2020) and American Tobacco, Philip Morris the electrical power generated. The continue increasing globally (20). Some International and Altria have purchased electrical power generated in the evidence from the tobacco industry shares in ENDS companies and/or device and the temperature to which itself suggests that, given the market developed their own brands (20, 21). the solution is heated can increase the growth in recent years, there has been There are now more than 30 000 ENDS amount of nicotine in the aerosol and an increase in total nicotine users (new (devices and e-liquids) brands sold in therefore delivered to the user. Some users) over recent years (23). the EU (20). ENDS have increased to more than 250W (earlier models were powered In 2014, ENDS generated US$ 2.76 ENDS devices vary greatly at about 10W), thereby increasing billion in global sales, rising to US$ 15 and are evolving rapidly the risk of users’ exposure to harmful billion in 2019. The total market value ENDS devices vary in shape, size and potentially harmful constituents of ENDS and heated tobacco products and functionality. New designs are (24–26).
ENDS SALES, CURRENT AND PROJECTED, BY UNITED NATIONS REGIONS
14 000
12 000
10 000
8000 Western European and other countries 6000 Asia-Pacific countries Eastern European 4000 countries Market size (US$, million) size (US$, Market 2000 Latin America and the Caribbean countries 0 African countries 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Source: (7)
Year
32 | WORLD HEALTH ORGANIZATION Examples of ENDS
Cig-a-likes Vape-pens These are disposables that have These enable users to vary e-liquid the look and feel of conventional formulations according to their cigarettes. This may renormalize preferences. Some use pre-filled smoking. cartridges while others allow users to refill them.
Disposables Tank systems These are the latest version of ENDS, These enable users to vary almost often shaped like pods, but are meant every element of the user experience, to be discarded after the e-liquid has including e-liquid formulations been used. They are available in a and battery power. wide variety of flavours and are also easily concealable. Pods
These are a newer generation of ENDS. Because this generation often uses nicotine salts, they provide higher doses of nicotine without a harsh sensation. The devices often look like USB sticks allowing users (e.g. young people or students) to conceal them.
electrical power generated in the There is a huge diversity in Nicotine e-liquids and their contents device, the puffing style of the user Nicotine is a highly addictive and the inclusion of ingredients in the Liquids differ greatly in their contents. substance contained in all ENDS and e-liquid have the potential to increase In addition to variable levels of nicotine, has reportedly been found in some users’ nicotine uptake (28). they often contain a wide variety of products marketed as ENNDS (14). flavourings, water, propylene glycol, The nicotine used in e-liquids may exist The nicotine contained in ENDS is usually glycerine and other compounds. in different forms. Free-base nicotine is often derived from tobacco, but some In addition, the aerosols generated by a modified form of nicotine present in products use synthetic nicotine. The these products after aerosolization of varying concentrations in conventional nicotine content of ENDS can range the liquid contain compounds, some cigarettes and can make cigarettes from 0 mg/ml to over 66 mg/ml or of which are toxic. Examples include more addictive by delivering nicotine more (at least twice the nicotine formaldehyde, which is a cancer-causing rapidly to the brain. More recently, content of a standard cigarette). Several agent (27). Some of the most common ENDS manufacturers have developed factors other than concentration can liquids components are as follows: nicotine salt formulations that deliver determine the amount of nicotine to higher levels of nicotine to the user which the user will be exposed. The while masking its harshness (29).
There are approximately 16 000 unique flavours available in some markets, many of them appealing to children.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 33 contribute to promoting and sustaining Flavours Propylene glycol (PG) and glycerol the use of tobacco products, while There are approximately 16 000 unique flavours such as cinnamon can improve These compounds are present in almost flavours available in some markets, the palatability of products (34, 35). all ENDS as carriers of nicotine and some many of them appealing to children The figure below illustrates a flavour flavourings used in these products. The (17, 18, 30, 31). These flavours can wheel for e-liquids in which more ratio of these two compounds often mask the harshness of nicotine and play than half of the flavours are those that determines the e-cigarette experience as a role in a person’s decision to try using appeal to children and adolescents (36), they can affect the smoothness, “throat ENDS for the first time (32). Flavours while other fruity and menthol flavours hit” and the plume (cloud) generated can make the use of the product more may also appeal to specific adult during use. PG is frequently used as an pleasurable, the inhalation of aerosols populations (e.g. women or certain additive in some foods and is “generally easier, and change the perceived risk ethnic groups) and non-smokers recognized as safe” when ingested associated with their use (33). For (32, 37). orally. However, its effects when inhaled example, flavours such as menthol have not been well studied.
E-liquid flavour wheel
With so many flavours available on the market, researchers have proposed this tool to classify e-liquid flavours and provide a shared and comparable vocabulary.
Ot y l V co er H o a he h Ch o nilla int r n Ot C r Mint a o ey m d Ot r c Tobac amel olate Menth Wi her Othe lnut ) G n er e Gum Almon t u Pepper an Co mm Haze r tton Candy onl base PG/VG Pec Bu y ut (But bb Bear n Othe on Ot le am he G s Pea n ove W r in Cl af um C ice fl r Quick Breade ico L meg Mu Nut r ffi eppe Ice Creamn P r Othe Don te ut fè Lat Custar Caf cino d ppuc Cu Ca e pcake Coffe Cream Espresso Cookie E-liquid Tea Cheese Flavour Wheel Other Cereals E.J.Z. Krusemann et al. Absinthe (2018) e Bourbon Cak Champa Butter gne Daiq Bananas Foster uiri Piña Mojit Apple Pie Col o er n ad h elo a Ot m te Rum ter na Wa a Sco egr tch Pom Vodka um W Pl En i Othe ne Pear er Lemonag Co Peach e y Dr r ap l rry a Gr e in k Ch Milk d
er e y So Apple h go O
n t d err h Ot e a
conut r e
n
eberry
Ma nana ackberry pb r l
Co a he e er lu
ang B
h
as B rawberry mo
Ot B
Or R
Lim St Le Ot Source: (36)
34 | WORLD HEALTH ORGANIZATION Studies in the United States of America show how flavours play a major role in e-cigarette use amongst children and adolescents:
■ Since 2011 the use of e-cigarettes amongst high school students in the United States has increased from 1.5% to 19.6% in 2020 (Graph 1). While there has been a recent dip in the prevalence of users, the rates continue to be worryingly high.
■ From 2014 to 2020, the proportion of current e-cigarette users using flavoured e-cigarettes increased from 65.1% to 84.7%.
■ Among high school students who currently used any type of flavoured e-cigarette, the most commonly used flavour types were fruit (73%), mint (56%), menthol (37%), and candy, desserts, or other sweets (37%) (Graph 2).
■ 70% of current youth (ages 12–17) e-cigarette users say they use e-cigarettes “because they come in flavours I like”.
GRAPH 1: GRAPH 2: CURRENT E-CIGARETTE USE (PAST 30 DAYS) FLAVOURS USED BY HIGH SCHOOL STUDENTS AMONG HIGH SCHOOL STUDENTS IN THE UNITED STATES CURRENTLY USING IN THE UNITED STATES FLAVOURED E-CIGARETTES
30% 80%
70% 25% 60% 20% 50%
15% 40%
30% 10% 20% 5% 10%
0% 0% Fruit Mint Menthol Candy/dessert
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 flavours flavours flavours flavours
Source: (38–40)
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 35 Many of the long-term health effects of ENDS use are still unknown, there is growing evidence to demonstrate that these products are not harmless.
Diversity of ENDS presents a vitro, and is likely to be associated dependent (54). Young people who challenge to understanding, with asthma and chronic obstructive experiment with ENDS are two to three monitoring, and regulating them pulmonary disease (47, 48 ). times as likely to progress to regular use of conventional cigarettes than ENDS have evolved differently The health impacts on users of these those who do not (55). If an ENDS depending on the regulatory products are also likely to depend user transitions to the use of tobacco environment of a given region, and on the many factors associated with products they will become vulnerable demographic contexts and markets. the range of ENDS design and how to the health outcomes associated In addition to the diversity of ENDS they are used, as well as on other with tobacco use, such as cancer, designs, product types and variants, products that the user is consuming cardiovascular disease, respiratory interchangeable parts, and the wide at the same time, and the quantity diseases and hypertension. variety of e-liquids and flavour types that or pattern of that consumption. For the user can themselves mix, many ENDS example, ENDS are often used as Nicotine also poses health risks to are also customizable by the user post- complements to cigarette smoking children, adolescents and pregnant sale, and some can even be manipulated and not as substitutes, especially in women. The consumption of remotely by the manufacturer (41). the smoke-free environments where nicotine in children and adolescents Customizable devices mean that they ENDS use is not banned. This means has deleterious impacts on brain can be manipulated by changing many ENDS users use both ENDS and development, leading to long-term different aspects of the products, such conventional cigarettes (dual use) consequences for brain development as the battery power, the heating coil (49) – a pattern of use that may in and potentially leading to learning and and the temperature that the heating fact have more deleterious effects on anxiety disorders (56–58). Nicotine component reaches. This can have a users’ health than the use of ENDS exposure in pregnant women can have significant impact on the emissions to or conventional cigarettes alone. In similar consequences for the brain which users and bystanders are exposed. the United States, almost 70% of development of the fetus (59, 60). adult ENDS users also currently smoke There is growing evidence of cigarettes (50). Dual use of ENDS and Other e-liquid components can harmful effects of ENDS cigarettes may also sustain nicotine also be harmful to health Tobacco and related industries dependence. Some studies suggest that Aside from nicotine, some of the market and promote ENDS as “safer” dual use is associated with increased common components of e-liquids are alternatives to conventional cigarettes risk of respiratory and cardiovascular known to have health effects, while and many users perceive them to conditions relative to single product use little is known about many more be significantly “less harmful” than (51–53). (25, 61). Some of the flavours used in tobacco products, especially cigarettes ENDS and ENNDS, for example, have (42). However, even though many of Nicotine is deleterious to been shown to increase the toxicity the long-term health effects of ENDS adolescent brain development of their aerosols (62). Aldehydes use are still unknown, there is growing and poses risks during pregnancy like vanilla and cinnamaldehyde evidence to demonstrate that these Nicotine is highly addictive. A flavouring, for example, have been products are not harmless (43). For non-smoker who uses ENDS may shown to contribute to toxicity and example, recent studies suggest that become addicted to nicotine and find the component used to bring about ENDS have negative acute effects on it difficult to stop using ENDS and/ buttery flavours is known for causing cardiovascular health, including heart or become addicted to conventional bronchiolitis obliterans (sometimes rate and blood pressure (44–46), and tobacco products. Given that many called “popcorn lung”) (47). that daily ENDS use has been shown ENDS are marketed to be attractive The outbreak of electronic-cigarette to be associated with increased risk to youth, they have been taken up or vaping product use-associated of myocardial infarction. In addition, by adolescents and children in large lung injury (EVALI) in the United studies on the impact of ENDS use on numbers in some countries. Nicotine States in 2019–2020 highlights the respiratory health show measurable addiction is generally established in potential dangers associated with these adverse effects on organ and cellular adolescence, creating a very real risk products. According to the most recent health in humans, in animals, and in of young users becoming nicotine data from the Centers for Disease
36 | WORLD HEALTH ORGANIZATION Children and adolescents that use ENDS are more than twice as likely to use conventional cigarettes.
Control, EVALI resulted in a total of the products are not of the expected of nicotine, particulate matter and 2807 cases and 60 deaths (63). While standard or are tampered with by potential carcinogens in second-hand the cause of these deaths has not been users. Accidental exposure to the high aerosols (SHA) exceed the maximum conclusively determined, vitamin E nicotine concentrations in e-liquid can recommended levels set out in the acetate (VEA), a common additive in also be very dangerous and even cause WHO FCTC Guidelines (72–74). This ENDS that contains cannabis (or THC), death. Cases of accidental ingestion of is of concern, as human exposure is thought to have played a significant the poisonous e-liquid by children are to particulate matter generated role in these cases of lung injury (64). particularly concerning, with one study during the use of ENDS – including While VEA is safe when consumed finding over 8000 exposures among fine and ultrafine particles (which orally in foods and when used on the children under the age of 6 years over may penetrate the alveoli), volatile skin, the impact of inhaling VEA is not a 5-year period in the United States organic compounds, heavy metals and fully understood. This is an example of America. Amongst these cases, nicotine (75) – have been shown to of why ENDS should be regulated and eight children suffered major health be associated with increased risk of some jurisdictions, such as Canada, the consequences and one 1-year old boy heart and lung disorders. Although the United Kingdom of Great Britain and died (65–68). health risks associated with SHA from Northern Ireland (the United Kingdom), ENDS are not yet well understood, and some states in the United States, Second-hand emissions have the a systematic review concluded that currently prohibit this additive (41, 65). potential to harm bystanders ENDS “vapour” has the potential to cause harm to bystanders (71). Further Electronic delivery systems have Studies show that ENDS use raises research is needed to fully understand also been linked to a number of airborne concentrations of particulate the health effects of second-hand physical injuries, including burns from matter above background levels when exposure to ENDS aerosols. explosions or malfunctions, when measured indoors (69–71). The levels
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 37 Prevalence of adult ENDS use is that of HTPs (23) makes it difficult ENDS use among children low, but varies and fluctuates to know which products people are and adolescents increases greatly across countries using and how they are using them. the chances they will use Surveillance criteria must be particularly While reliable data are not available conventional cigarettes and stringent and meticulous to capture for all countries, current ENDS use other tobacco products the current and evolving nuances among adults varies greatly across ENDS use among children and that exist among these products and the countries that monitor it, from adolescents under the age of 20 years patterns of use across countries. 11% in Estonia (2018) to 0.2% in is of concern in many countries, not Uruguay (2016-17) – see Annex II ENDS use among children and only because of the detrimental effects and Annex XI. ENDS use rates can adolescents must be prevented of nicotine in this age group but also also change rapidly in a population because most young ENDS users are over a short period of time (41): in A recent systematic review found non-tobacco users, and ENDS use Great Britain, the prevalence of adult that the prevalence of ENDS ever-use may lead to future consumption and ENDS use rose to 7.1% in 2017 and among children and adolescents across addiction to tobacco products decreased to 6.3% in 2020 (49). all countries and territories that had ( 67, 80 ). In other words, ENDS data (50 out of the total 67 countries may act as a “gateway” to tobacco Increasingly, population-level surveys that reported on ENDS use in some include questions about the use of consumption (81). A global systematic dimension) was estimated to be 19.9%. review recently found that those ENDS (as well as ENNDS) among For current use of ENDS (use in the last both adults and adolescents. children and adolescents that use 30 days) the pooled estimate across 60 ENDS, even when experimental in Questions have been incorporated countries was 8.8% (77). And in the into Tobacco Questions for Surveys nature, are more than twice as likely United States, the extent of e-cigarette to later use conventional cigarettes (TQS) (76). The diversity of products use among children and adolescents (both ever and current use) (82). and nomenclature, however, pose led the US Surgeon General to declare a real challenge for monitoring and the problem an epidemic in 2019 (78). surveillance of these and other novel More recent surveys have observed a and emerging nicotine and tobacco decline in the prevalence of e-cigarettes products. In addition, the conflation use in this population but trends must of the ENDS product category with be carefully monitored (79).
38 | WORLD HEALTH ORGANIZATION Evidence on the potential products, the quitting of any tobacco is available, electronic cigarettes role for ENDS in cessation product or the quitting of any nicotine should only be considered to support is still inconclusive product. In the Cochrane Review, smoking cessation for a limited time cessation was considered successful and under supervision” (85). Indeed, To date, evidence on the use of ENDS if people quit smoking any tobacco some research has suggested that, as a cessation aid is inconclusive. A product. In other words, a person could in some cases, ENDS could hinder recent Cochrane Review suggests that move from conventional cigarettes to cessation in some individuals by e-cigarettes can help smokers quit ongoing use of ENDS and be considered prolonging or increasing addiction to (83). This review compared ENDS to to have successfully “quit”. This leaves nicotine (86).Given the diverse nature behavioural support and other nicotine open the question about the duration of ENDS, more evidence is needed to replacement therapy (NRT) and pooling for which a person would be expected inform a conclusive statement on the the results of four studies found a small to continue using ENDS as a cessation potential of any specific ENDS product but significant increase in quitting rates device, especially since longer-term use as a cessation tool. At this time, among ENDS users. The results suggested may entail increased exposure to the there are still a number of unknown that out of 100 people using NRTs, six of potential health risks associated with factors which mean that ENDS cannot them are likely to quit successfully, while ENDS. NRTs are designed such that be recommended as cessation aids 10 out of 100 people using e-cigarettes nicotine content is progressively reduced at the population level. Currently to quit are likely to be successful. throughout the treatment so as to available cessation treatments such There are a number of caveats to this reduce dependence on nicotine. as NRTs (gums and patches), and conclusion. Firstly, the authors note that pharmacotherapies (Bupropion and The US Surgeon General’s Report on the certainty of these findings is low (for Varenicline), must be approved by Cessation concluded, “The evidence is the comparison to behavioural support) each country’s regulatory authority inadequate to infer that e-cigarettes, in to moderate (for the comparison to before they can be marketed and made general, increase smoking cessation” NRTs). Secondly, the studies included available in that country and comply (84). In addition, the European used a single product type in a with regulatory requirements (87). Union’s Scientific Committee on therapeutic environment, and this is not ENDS are not currently subject to this Health, Environmental and Emerging considered comparable to the current regulatory approach in most countries Risks (SCHEER) Opinion on electronic real-world context of e-cigarette use. where they are sold, and consequently cigarettes concluded, “There is a Thirdly, and perhaps most significantly, do not benefit from the same quality lack of robust longitudinal data on there is the question of defining assurance and oversight guaranteed the effect of electronic cigarettes on cessation. Cessation may be seen to for other cessation treatments. smoking cessation. Until such research be the quitting of smoked tobacco
ENDS by prescription: the unique case of Australia
On 1 October 2021 Australia Administration (a regulatory agency young people in Australia. Between will become the first country in of the Australian Government) for 2016 and 2019, the proportion of the world to ban the purchase access to the unapproved product young people aged 18–24 years or import of ENDS by consumers before they issue a prescription. who reported using e-cigarettes unless they have a valid doctor’s Patient access to these products daily, weekly, monthly or less prescription to do so. The main is restricted to certain pathways than monthly at the time of being reason a doctor may provide a available for ‘unapproved’ surveyed nearly doubled, from prescription is to help the user quit. prescription medicines. Further 2.8% to 5.3%. The regulations also information is available at: provide an opportunity for current As there are currently no https://www.tga.gov.au/nicotine smokers to receive appropriate approved nicotine e-cigarettes -e-cigarettes. advice from a medical doctor on on the Australian Register of the benefits of smoking cessation Therapeutic Goods (ARTG), The tightened ENDS regulations and the risks associated with ENDS. doctors themselves may need to aim to stem the increase in the apply to the Therapeutic Goods use of nicotine e-cigarettes by Source: (88)
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 39 Potential impact of ENDS on the ENDS present important The emergence of ENDS in wider population who do not threats and challenges to many countries may undermine currently use tobacco or ENDS tobacco control tobacco control progress Apart from the question of whether Tobacco control has made significant ENDS proponents argue that the ENDS can help tobacco users quit, there progress over the last two to three presence of “less-harmful” alternatives are many other questions raised by decades. This report finds that the can help reduce the prevalence of ENDS in relation to patterns of tobacco global prevalence of smoking has tobacco use and improve the health of consumption (89). For example, to what reduced in just the past 12 years from the population. But while innovation in extent do people, in particular adults, 22.7% in 2007 to 17.5% in 2019, and cessation products is to be welcomed, reduce their tobacco use (if at all) when with the adoption of measures like ENDS are currently marketed to attract they start using ENDS? And how does smoke-free environments in many new users (i.e., not limited to tobacco this differ between the type of ENDS or countries, at national, provincial users wanting to quit) and misinform ENNDS used? At the population level, and city levels, tobacco use has the public about the risks associated does the availability of ENDS on the been denormalized (91). Legal with their use in the absence of robust market increase or decrease cessation restrictions have protected children evidence (or indeed in the face of attempts? Are ENDS attractive to and adolescents from the harms of growing evidence to the contrary). former smokers and do long-term tobacco by restricting the age of ENDS currently pose significant former smokers start using ENDS (90)? purchase and ensured bans against challenges to public health and could And, if indeed ENDS help people to quit advertising of tobacco products. undermine some of the hard-won smoking, how does this health benefit Today, over 5.3 billion people are progress in tobacco control achieved compare to the risks of increasing protected from the harms of tobacco to date. numbers of children and adolescents by at least one MPOWER measure. initiating the use of these products (89)? Many of these questions have no quick answer, and answers might not be generalizable to all countries, but ensuring ENDS are adequately regulated to protect population health can be achieved immediately. If they are not appropriately regulated, they may undermine current measures intended to protect people’s health.
40 | WORLD HEALTH ORGANIZATION How ENDS challenge tobacco control and effective public health implementation
Legislation and regulatory Because ENDS often do not have the same characteristics as conventional mechanisms struggle to products and are constantly evolving, they may not be covered under existing keep pace with changing laws and can fall between regulatory cracks. In particular, open-system product characteristics (modifiable) ENDS are difficult to regulate (92) and regulations are often not able to keep pace with changing product characteristics.
ENDS use among children ENDS are aggressively marketed towards children and adolescents, including and adolescents may act as through the use of flavouring and promotional strategies (93, 94) and their use a gateway to tobacco use could lead young people to take up more harmful forms of nicotine or tobacco consumption. The advent of high-concentration nicotine solutions and nicotine salts may increase a new user’s dependence on nicotine and increase their likelihood of moving on to conventional tobacco cigarettes (95, 96).
ENDS subvert tobacco Many ENDS users cite the ability to get around smoke-free restrictions as a control laws and thereby major motivation for using these products (97). If ENDS are not banned in undermine tobacco control smoke-free spaces, people will not only be exposed to second-hand emissions achievements but existing bans on tobacco products such as HTPs (which can be difficult to differentiate from ENDS) may be more difficult to implement, thus undermining the measures in place to protect by-standers.
ENDS are renormalizing ENDS use mimics the behaviour of smoking by the hand to mouth movement, smoking in society with the aerosol generated bearing close resemblance to tobacco smoke. Where regulations do not exist to restrict it, the use of ENDS in public spaces may make people more comfortable around those using them and may increase acceptance of smoking (98, 99).
ENDS may entice former ENDS may remind people of smoking and result in former smokers taking up smokers to take up ENDS ENDS or relapsing to use tobacco products again (100).
ENDS may discourage It is still unclear if ENDS use is likely to eventually lead to cessation. Switching smokers from fully quitting from tobacco to ENDS or dual use may prolong the use of tobacco products by prolonging dual use beyond what would have been the case had users been relying on NRTs or other or continuing their use of evidence-based interventions to quit (86, 101, 102). nicotine products
Regulating ENDS must not exact harm or level of risk that ENDS goals of tobacco control cannot be distract from work to strengthen will have on population health in the neglected. Where tobacco control laws tobacco control in general future is not known, but currently the are firmly in place, it will be possible to number of people using these products leverage more effective responses to One of the major concerns associated is only a fraction of the number ENDS and other novel and emerging with ENDS is that they are a deliberate exposed to the known harms of nicotine and tobacco products. distraction from work to prevent the tobacco (54). While a close eye must be more than 8 million deaths each year maintained on these products, the main that result from tobacco use (103). The
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 41 “…each Party shall, in accordance with its capabilities, adopt and implement effective legislative, executive, administrative and/or other measures and cooperate, as appropriate, with other Parties in developing appropriate policies for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke.”
Article 5.2 WHO FCTC
There are many regulatory products. But in the long-term, countries MPOWER at the highest level; the mechanisms and options to should ensure that their tobacco control regulatory authority over these products; protect populations against ENDS laws and regulations are comprehensive the country’s tobacco control policy enough to regulate all forms of novel goals; the available resources and This report finds that a total of 32 and emerging nicotine and tobacco capacity to regulate a highly complex set countries currently ban ENDS. Where products, thereby ensuring that the of products in a changing environment; ENDS are not banned, they should be relevant industries do not exploit any and the size of the existing ENDS market regulated, and there are a number of regulatory or legal loopholes to sell and in that country (50). Effective policy different approaches that countries have market these products (for example, toolkits already exist (such as MPOWER) taken to do so (104). Given the speed at classifying ENDS as smokeless tobacco that should be applied productively which ENDS markets are growing and may mean that they can be used in to ENDS, as well as ENNDS (see table its products are evolving, it is necessary indoor public spaces). below). Guidance provided by the WHO to apply regulatory controls on ENDS report to the 2014 Conference of the immediately. This may mean temporarily Effective adoption and implementation Parties (FCTC/COP/6/10 Rev.1) and banning these products or temporarily of regulatory measures will depend further elaborated in WHO’s 2016 report classifying them according to an existing on a number of factors including: to the seventh session of the Conference category such as tobacco products, the country’s achievements to date of the Parties (outlined on facing page) pharmaceutical products or consumer to implement the WHO FCTC and remain relevant.
HOW MPOWER CAN BE APPLIED TO ENDS
Demand Reduction Measures
Governments are recommended to use their existing tobacco surveillance and monitoring systems to assess M developments in ENDS and nicotine use by sex and age.
ENDS non-users should be protected from exposure to ENDS emissions. Indoor smoke-free places should P never exempt ENDS (or ENNDS or HTPs) from a ban.
Evidence on the use of ENDS as a potential tobacco use cessation aid is still under debate and there is O insufficient evidence to support their use at the population level, as compared to proven approaches. Countries should also use evidence-based approaches to support ENDS users who want to quit (105).
Strong graphic health warnings should be mandated for all ENDS products, in line with overall tobacco W control strategies to deter use by young people.
Given that the same promotional elements that make ENDS attractive to adult smokers could make them attractive to children and non-smokers, effective banning on ENDS advertising, promotion and sponsorship E should be enforced. Further recommendations on the regulation of advertising, promotion and sponsorship of ENDS can be found in FCTC/COP/6/10 Rev.1 (106)
ENDS on their own carry health risks. Therefore, taxes should be applied to these products, in line with R national standards, to prevent uptake, particularly among children and adolescents (see WHO’s Technical Manual on Tobacco Tax Policy and Administration for more information) (22).
Other policy approaches beyond MPOWER should also be applied. A ban on flavours, as has been implemented in Finland, can reduce the attractiveness of ENDS, particularly to minors. Furthermore, like tobacco, banning the sale and distribution of ENDS to minors should be adopted globally and Internet and other remote sales should be banned to avoid the potential use of this service to circumvent age restrictions and other regulations.
42 | WORLD HEALTH ORGANIZATION Recommendations Countries should:
■ Ensure continued focus on comprehensive evidence-based ■ Where a ban on manufacture, sale and distribution of ENDS tobacco control measures to reduce nicotine addiction is the preferred regulatory approach to protect the health and tobacco use through all provisions of the WHO FCTC of a country’s population (in the wider context of tobacco and full implementation of MPOWER. This is a priority. control, and based on the specific domestic regulatory environment), countries should strictly implement the ban ■ Where manufacture, sale and distribution of ENDS is without any interference from the industry to ensure a high not prohibited, adopt appropriate regulatory options to degree of protection for children and adolescents. achieve the key objectives of protecting the population from potential health risks; preventing unproven claims ■ Monitor the use of ENDS and ensure that data being made about ENDS; and protecting tobacco control are disaggregated by age and sex. National activities from commercial interests (107). See box below representative surveys must capture use of all forms for a summary of regulatory options. of novel and emerging products such as ENDS so that researchers can perform rigorous analyses, ■ Consider prohibiting the sale of ENDS that the user can and regulatory approaches are well-informed. modify (either its features or e-liquid ingredients) (50). ■ All these recommendations should also be applied to ENNDS.
Objectives and options for regulating ENDS and ENNDS (based on the COP Decision FCTC/COP6/10/rev)
OBJECTIVE: OBJECTIVE: Prevent the initiation of ENDS and ENNDS use Prevention of unproven health claims being by non-smokers and youth, with special attention made about ENDS and ENNDS to vulnerable groups Measures may include prohibiting implicit or explicit Measures may include banning the sale and distribution, claims about the effectiveness of ENDS/ENNDS as well as the possession of, ENDS and ENNDS by minors; as smoking cessation aids unless a specialized banning or restricting advertising, promotion and governmental agency has approved them; prohibiting sponsorship of ENDS/ENNDS; taxing ENDS/ENNDS at a implicit or explicit claims that ENDS/ENNDS are level that makes the devices and e-liquids unaffordable innocuous or that ENDS/ENNDS are not addictive; to minors; banning or restricting the use of flavours; and prohibiting implicit or explicit claims about the regulating places, density and channels of sales. comparative safety or addictiveness of ENDS with respect to any product unless these have been OBJECTIVE: approved by a specialized governmental agency. Minimize as far as possible potential health risks to ENDS and ENNDS users and protect non-users OBJECTIVE: from exposure to their emissions Protect tobacco control activities from all commercial and other vested interests related a. To minimize health risks to users: Testing heated to ENDS and ENNDS, including the interests of and inhaled flavourings used in the e-liquids for safety the tobacco industry and banning or restricting the amount of those found to be of serious toxicological concern; requiring the Measures to do this are outlined in detail in the next use of ingredients that are not a risk to health and are, chapter. Briefly, measures may include rejecting when allowed, of the highest purity. partnerships with the industry; raising awareness about b. To minimize health risks to non-users: potential industry interference with Parties’ tobacco Prohibiting by law the use of ENDS and ENNDS in control policies; treating state-owned industry in the indoor spaces; requiring health warnings about same way as any other industry; banning activities potential health risks deriving from their use. Health described as “socially responsible” by the industry and warnings may additionally inform the public about the taking measures to prevent conflicts of interest for addictive nature of nicotine in ENDS; and reducing the government officials and employees. risk of accidental acute nicotine intoxication.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 43 TOBACCO INDUSTRY INTERFERENCE: STRENGTHENING RESPONSE IN THE FACE OF EVOLVING TACTICS
Despite the more than 8 million tobacco use-related deaths each year (103), The many faces of tobacco industry interference the tobacco industry continues to Tobacco industry tactics to thwart tobacco cessation are not new (109). aggressively market its products The Stopping Tobacco Organizations and Products (STOP) partnership has worldwide and to undermine identified nine common tobacco and related industries’ tactics ( 90, 110 ) : implementation of the WHO FCTC and the MPOWER package. But TACTIC 1 TACTIC 6 implementation of the WHO FCTC Building alliances and front groups Influencing “upstream” policies, benefits from strong governmental to represent its case – the “third including trade treaties, to make it commitment to eliminate this party technique” harder to pass public health regulations interference. Parties to the Convention are legally obliged (under Article TACTIC 2 TACTIC 7 5.3) to “protect these policies from Attempting to fragment and weaken Litigating or threatening litigation commercial and other vested interests the public health community of the tobacco industry in accordance TACTIC 8 with national law” (108). However, the TACTIC 3 Facilitating and causing confusion tobacco industry invests considerable Disputing and suppressing public around tobacco smuggling, using resources to oppose strong tobacco health information it to fight tobacco control control measures, both at national and international levels. Following TACTIC 4 TACTIC 9 failed attempts to prevent, delay, or Producing and disseminating Seeking to manage and enhance its derail negotiation of the WHO FCTC misleading research and information own reputation in order to increase (as well as to weaken it), the tobacco its ability to influence policy industry now strives to subvert its TACTIC 5 comprehensive implementation by deploying a wide variety of strategies Directly lobbying and influencing to obstruct tobacco control measures. policy-making Some of these strategies are public while others are more covert. Overall, however, the goal is to weaken Countering tobacco industry tactics effective tobacco control. Countering industry interference interference and should be applied in is fundamental to effective the context of both conventional and WHO FCTC implementation. In 2008, emerging nicotine and tobacco products. the Conference of Parties (COP) to the The tobacco industry attempts to present WHO FCTC adopted guidelines for the itself as a partner in tobacco control, implementation of Article 5.3. These while simultaneously blocking regulatory were based on both scientific evidence efforts. Therefore, partnerships with and the experiences of Parties, and tobacco and related industries should aimed to assist Parties in achieving their be rejected, and there should be clear legal obligations under the WHO FCTC. rules regarding conflicts of interest for government officials and government These guidelines continue to be employees working on tobacco control. instrumental in combatting industry
44 | WORLD HEALTH ORGANIZATION Whenever tobacco companies have faced a major threat, they have introduced new products promising they would be less harmful than conventional cigarettes. Ultimately, they just undermined progress while providing the industry with a new way to make money.
Government action to counter tobacco industry interference should include the following: Tobacco and related
■ Requiring disclosure of, and clearly ■ Requiring that information from industry interference communicating, funding sources for the tobacco industry on marketing, and ENDS research institutions, academics, and lobbying and philanthropic activities scientific studies to prevent unseen is disclosed and that the information “Whenever tobacco companies biases in science on which policy provided by them be transparent have faced a major threat, they have may be based, as well as to clarify and accurate, with regular, truthful, introduced new products promising the motivations of nongovernmental complete and precise information they would be less harmful (than organizations, business and trade on tobacco industry activities. All conventional cigarettes). They used associations, consumer groups, think government interactions with the these products to protect their tanks, professional associations and industry should be recorded and sales and position themselves as others seeking involvement or input made available to the public. part of the solution and re-connect in tobacco control policies. with policymakers. Ultimately, ■ Putting in place and enforcing they just undermined progress ■ Rejecting partnerships and effective conflict of interest while providing the industry with non-binding or non-enforceable policies for policy-makers and a new way to make money.” agreements with the tobacco officials engaged in developing, industry and those working in its implementing and enforcing STOP Initiative (113) interests, including financial support, tobacco control policies. The tobacco and related nicotine incentives and endorsement of ■ Treating state-owned tobacco industries1 use a number of strategies tobacco industry activities related enterprises the same as other to sell their products. The following to tobacco control. tobacco companies. No government outlines some of the key tactics ■ Raising awareness about the known privileges or influence should identified regarding novel and addictive and harmful properties be afforded to any tobacco and emerging products. of tobacco and nicotine-containing nicotine companies. products, and about tobacco Attracting new customers and ■ Ensuring that non-health agencies industry interference with tobacco sustaining existing customers take the same action, adhering control policies. to Article 5.3 and applying the ENDS are aimed at attracting ■ Denormalizing and, to the extent Guidelines for Implementation. new, young users possible, regulating and banning ■ Blocking interaction between publicity around activities described Tobacco and ENDS companies use government and front groups that as “socially responsible” by the product design features that increase are funded by tobacco and related tobacco industry. the attractiveness of the products, industries “purporting to work for especially to young users. The products ■ Prohibiting the dissemination of a smoke-free world” (speech by look like sleek new technology and misleading information relevant Dr Tedros Ghebreyesus) (111). are often sold in stores that are to tobacco control policies. glamorous and hyper modern. Some Governments should encourage and empower civil society to play a role in of the designs associated with ENDS preventing and addressing tobacco industry interreference. Effective advocacy look like small USB sticks and are small against the tobacco and nicotine industries requires skills training, capacity enough to hide from others, making building and longer-term investments from donors to ensure sustainability (112). them particularly useful in the school
1 “Nicotine industry” means manufacturers, wholesale distributors and importers of nicotine and non-nicotine products, including associations or other entities, as well as industry lobbyists. WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 45 environment where students can keep Dissemination of misinformation concerns around the scientific research them concealed from teachers and and interference with scientific conducted by Philip Morris International other authorities (114 ). Furthermore, research (PMI) on HTP aerosols and the failure the products are promoted at youth- of the company to make available data friendly events such as music festivals, Misinformation about ENDS, from longer term studies (118 ). and manufacturers use social media as well as HTPs influencers that appeal to young Conflation of product categories HTPs, ENDS and ENNDS are often audiences to promote them (115). Other promoted by the industry as “safer” product characteristics that attract Blurring the lines between ENDS alternatives to conventional tobacco. new users are the use of an enormous and HTPs and creating confusion They are also promoted or indirectly range of flavours that particularly over their associated risks framed as cessation products that can appeal to children and adolescents. help tobacco users quit conventional When expedient, such as to benefit smoking. Such activities have from lighter regulation, tobacco Sustaining addiction among ramifications for proven interventions companies pitch HTPs as electronic the customer base to assist tobacco cessation, as they have products “similar to ENDS”. Yet, where E-liquid contents are also designed to the potential to misinform and mislead ENDS are banned, HTPs are pitched keep people coming back for more. For consumers. Based upon misinformation, as tobacco products that do not fall years tobacco companies have included individuals who want to quit may opt within existing categories (119 ). This additives in conventional cigarettes, for the use of products with which they creates confusion about these product such as acids and ammonia, to make have a lower chance of success. categories, both among the general cigarettes more palatable, decrease public and for regulatory purposes. HTPs are tobacco products and should the harshness of nicotine and enhance A significant amount of research be regulated as such, with application nicotine delivery to the brain (116 ). is funded by the tobacco and of the WHO FCTC, but by blurring the Similarly, in some ENDS, nicotine salts nicotine industries (see page 33) for example not only difference between HTPs and ENDS Despite unquestionable and inevitable help increase the palatability of product the industry attempts to circumvent conflicts of interest, a substantial use, they also deliver larger amounts strict regulation (120). HTPs are often amount of the available literature of nicotine to the user which is likely promoted, especially to regulators, on novel and emerging nicotine to increase their addictiveness. as smoking cessation aids. However, and tobacco products is funded by there is no reliable tobacco industry product manufacturers including the independent evidence on the impact tobacco industry (117). This creates of HTP use on conventional smoking many challenges when interpreting cessation. HTP use is tobacco use. the evidence, as selective and Indeed, more generally, there is limited favourable results are more likely to evidence on the long-term health be reported and presented to the impacts of HTPs. public. For example, there are serious
Tobacco and ENDS companies use product design features that increase the attractiveness of the products, especially to young users.
46 | WORLD HEALTH ORGANIZATION PMI International exploits confusion over HTP classification
HTPs and ENDS those being pursued by other permit the company to make any tobacco industry actors. other modified risk claims or any HTPs and ENDS are sometimes express or implied statements that conflated by companies. In its convey or could mislead consumers “Hold my light” campaign, Philip PMI exploits the confusion into believing that the products are Morris International (PMI) has over the FDA decision endorsed or approved by the FDA, itself described HTPs as being To support their claim that HTPs or that the FDA deems the products “like e-cigarettes”. This is deeply are safer products, PMI submitted to be safe for use by consumers.” problematic because HTPs are an application to the United States tobacco products, which means Food and Drug Administration On 27 July 2020 WHO issued a they have different risks. (FDA) to classify HTPs as a statement reminding Member “modified risk tobacco product”. States that are Parties to the HTPs help to hook On 7 July 2020, the FDA granted WHO FCTC that HTPs are tobacco new consumers an “exposure modification” order products, meaning that the but denied the “risk modification” WHO FCTC fully applies to these Recent investigations have order for which PMI had applied. In products. Specifically, Article shown that PMI has sought to other words, reducing exposure to 13.4(a) obliges Parties, to prohibit expand its market by aiming to harmful chemicals in HTPs does not “all forms of tobacco advertising, attract consumers who are not render them harmless, nor does it promotion and sponsorship that current smokers. To do this they translate to reduced risk to human promote a tobacco product by any use marketing pricing strategies health (121). means that are false, misleading that establish their HTP product or deceptive or likely to create (IQOS) as an aspirational brand, Indeed, the FDA statement noted an erroneous impression about and not a product designed to that, “Even with this action, these its characteristics, health effects, attract smokers who want to products are neither safe nor hazards or emissions”. quit (23). PMI’s business model ‘FDA approved’. The exposure and tactics are representative of modification orders also do not
smoked tobacco across the world. Manipulating public opinion Controversies about “harm The British American Tobacco Annual to gain “respectability” while reduction” that divide public report, 2019 (122) demonstrates that undermining public health health communities functions and progress most of the profits generated through the sale of ENDS come not from Harm reduction is a public health Promoting ENDS in the name customers who have replaced their approach that aims to reduce the of public health while tobacco consumption with ENDS, but harm caused by substances or opposing effective tobacco rather from dual users who sustain the behaviours that are otherwise difficult control measures use of conventional tobacco while also to eliminate. Some have endorsed the using ENDS. The industry, therefore, idea that ENDS can be used as part The tobacco industry increasingly continues to reap profits from all of a harm-reduction approach, while positions itself as a legitimate partner possible avenues while acting as if others have warned of the importance and stakeholder in tobacco control, it is working to improve population of evidence to quantify the risk over the but its interests are fundamentally at health. Furthermore, there is emerging long-term, the risk associated with dual odds with control efforts. The tobacco evidence from prospective studies use of ENDS and cigarettes (a common industry simultaneously portrays to suggest that dual use may indeed pattern of use) and the risk of initiation themselves as working towards a be more harmful than conventional among children and adolescents (124). “smoke-free” future, while at the same cigarette use alone (123). time promoting – and making most The commercialization and marketing of their profits from – conventional of ENDS currently practiced by the
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 47 tobacco and related industries is not PMI’s “unsmoke” campaign (primarily prevent it, advertising can then use aligned with the cause of public health. focused on HTPs) encourages people brand names of tobacco products, While the tobacco industry claims to “who don’t quit cigarettes” to “change hence helping to sell not only the ENDS be committed to harm reduction, their to a better alternative” and is in line product but also the original branded duplicity is demonstrated by how they with PMI’s goal to “replace cigarettes tobacco product. simultaneously aggressively promote with the smoke-free products we’re tobacco products where they can, and developing and selling”. The campaign Interfering in legislative processes especially in low- and middle-income undermines tobacco cessation initiatives in countries, directly and through countries (23) continue to circumvent by presenting a tempting and easy front groups like Foundation for and undermine legislation to regulate “alternative” to breaking a nicotine a Smoke Free World conventional tobacco products (125, addiction, and undermining successful Over past years the tobacco 126), and take advantage of legislative tobacco control initiatives (which industry has interfered with tobacco loopholes for promotion and sale of have denormalized smoking in many control legislation at country level novel products (127). countries) by portraying this form of by attempting to slow tobacco tobacco use as socially acceptable. control or by preventing outright Industry tactics that interfere the advancement of tobacco control with the public health endeavour Interference to undermine measures. For example, PMI and groups in tobacco cessation current tobacco control measures funded by PMI, like the Foundation for Guidelines for Implementation of ENDS have created new ways for a Smoke Free World, use promotion Article 14 of the WHO FCTC define the tobacco industry to sidestep and other tactics to try pressure the phrase “tobacco cessation” as laws governing advertisments governments to allow these products “the process of stopping the use of into domestic markets and exempt any tobacco product, with or without ENDS have been openly advertised. them from tobacco control regulation assistance”. Nicotine replacement After decades of marketing restrictions, (in particular TAPS bans, taxes and therapies (NRTs) are designed to help the tobacco industry is once again smoke free laws), thereby undermining people quit tobacco, and eventually using media channels such as television, tobacco control initiatives and stop using NRTs as well. Switching from which were previously used to target weakening WHO FCTC implementation tobacco use to HTPs such as IQOS does youth and young adults. Without (23, 128). not constitute cessation of tobacco use. appropriate legislation in place to
Disappearing into regulatory gaps: the battle to regulate ENDS in Israel
While the Israeli government was However, in December 2018, the violated the rights of the Members developing legislation to govern Israeli legislature passed a new law of the Chamber. ENDS, a manufacturer called E-Cig governing both tobacco products In the end, Israel successfully Ltd applied for permission to import and ENDS, and which restricted amended its tobacco legislation and market an e-cigarette. The ENDS advertising and required plain to implement plain packaging government rejected the request on packaging for ENDS products. JUUL for smoking products, including grounds that the efficacy and safety Labs and the Tel Aviv Chamber of e-cigarettes, but the case shows of the product were not proven, Commerce (Chamber) challenged how companies want ENDS to and that importing it contravened these provisions on the grounds that fall within regulatory gaps. the country’s laws surrounding vaping products are less harmful pharmaceuticals. The company than cigarettes and could encourage Sources: (110, 119, 129) challenged the decision on the regular smokers to switch to grounds that ENDS were recreational ENDS. They argued that therefore, products and not pharmaceuticals, prohibitions and restrictions on and the court agreed. the advertising of vaping products
48 | WORLD HEALTH ORGANIZATION Countering the tobacco industry to overturn ENDS regulation in Thailand
When Thailand banned the import and sale of all types of ENDS in 2015, As the tobacco companies pro-ENDS groups lobbied the government to lift the ban after PMI began continue to press into more low- promoting its IQOS in 2017. ENDS Cigarette Smoking Thailand (ECST), a and middle-income countries, pro-ENDS group in Thailand, worked in parallel with Philip Morris Thailand more attention should be given Limited (PMTL) to oppose the ban, using six tactics: to past industry use of legal and administrative influences/measures ■ Creating front groups ■ Seeking to discredit tobacco to prevent this influence and control advocates ■ Lobbying decision-makers establish science-based regulatory ■ Funding tobacco-harm frameworks. Health advocates ■ Running public relations reduction research campaigns should also persuade non-health agencies to maintain policies in ■ Pitching government sectors against each other accordance with the WHO FCTC.
Despite strong opposition to the ban, the commitment of the Thai Source: (130) government and Thai tobacco control organizations (helped by tobacco workers union, which opposed the involvement of transnational tobacco companies in the Thai tobacco industry in order to protect the public from harmful tobacco products) has ensured that ENDS remain illegal (as of January 2021).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 49 TOBACCO AND THE COVID-19 PANDEMIC: THE LINKS
The question of tobacco’s role in or deaths due to COVID-19 are more COVID-19 cases and deaths arose early Tobacco’s role in infectious frequent in people with comorbidities in the pandemic and many studies respiratory diseases is related to tobacco use, including COPD, have attempted to better understand well established lung cancer, and cardiovascular diseases the relationship between tobacco and (131–134). There is currently only COVID-19. Tobacco compromises lung function, limited information on COVID-19 in relation to other tobacco products (e.g. While most cases of COVID-19 result in and COVID-19 primarily affects the heated tobacco products, waterpipe, no symptoms or only mild symptoms, in lungs. Smoking tobacco is also a cigars) and electronic nicotine delivery some individuals COVID-19 can trigger known risk factor for severe disease systems (e.g. e-cigarettes), although life-threatening pneumonia (131–134) from many respiratory infections (54), these products are thought to play an and other severe outcomes. People including coronaviruses SARS (first unfavourable role in COVID-19 severity suffering from obesity (135, 136) and identified in 2003) and MERS-CoV (first (148, 149). those with underlying conditions such documented in June 2012) (138–140). as cardiovascular diseases, diabetes, Smoking also impairs the immune and chronic obstructive pulmonary system and previous studies have disease (COPD) are at higher risk of established that tobacco use is linked Evidence on the biological more severe COVID-19 outcomes, with poorer outcomes for people with mechanisms linking TB (141) and pneumonia (142). Indeed, including admission to intensive care COVID-19 and tobacco units, the need for a ventilator, and in smoking increases pneumococcal, some cases death (137). Tobacco is a legionella, and mycoplasma pneumonia use is growing by three- to five-fold (143). known risk factor for these diseases Some evidence suggests biological as well as for infectious respiratory mechanisms involved in the viral diseases such as pneumonia and infection may make smokers more tuberculosis (TB). Smoking worsens vulnerable to COVID-19 (150). While COVID-19 outcomes these findings provide a plausible explanation for the observed association Current evidence indicates that smokers between smoking and COVID-19 (current and former) are more likely outcomes, they are not undisputed. At to suffer more severe outcomes of the same time, some have hypothesized COVID-19 (144). Multiple systematic that nicotine might be protective against reviews and meta-analyses conducted COVID-19 through anti-inflammatory on this issue provide evidence of a effects and the inhibition of cytokine direct association between cigarette storms. A clinical trial is underway to smoking and COVID-19 severity, with investigate the specific role nicotine smokers having a substantially increased plays in COVID-19 (151), but until more risk of COVID-19 progression and death information is available no conclusions (144–147) compared to non-smokers. should be drawn. Furthermore, severe forms of COVID-19
50 | WORLD HEALTH ORGANIZATION TOBACCO INFORMATION CAMPAIGNS DURING COVID-19
WHO European Regional Office media campaign launch in early 2020 to help keep people informed about the risks associated with tobacco in the context of the COVID-19 pandemic
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 51 TOBACCO INFORMATION CAMPAIGNS DURING COVID-19
South-East Asia Regional Office media campaign launched in the early months of 2020 to inform people of the risks associated with tobacco, e-cigarettes, sheesha and smokeless tobacco and betel nut use during the COVID-19 pandemic
52 | WORLD HEALTH ORGANIZATION Evidence and misinformation on the risk of contracting COVID-19
At the start of the pandemic there those in intensive care are often COVID-19 outcomes do not adjust was a great deal of confusion not even included in the published for relevant confounders such as about the potential link between case-series studies. age, making the interpretation smoking and COVID-19, due in part of results easily fallible. Furthermore, depending on the to misinformation in the media. context, some people would prefer Some early studies claimed that the not to share information about their Testing biases in population- prevalence of smokers identified tobacco use (young people who based cohort studies among hospitalized COVID-19 are hiding their consumption from Some studies have suggested that patients was lower than among adults for example, or contexts of those tested for COVID-19, the general population, leading where women feel it is socially results among smokers show lower some to claim that smoking, unacceptable), especially with their rates of positives and this has been and nicotine in particular, may doctor. Furthermore, given the taken to mean that smokers are be acting as a protective factor context of a respiratory disease less likely to acquire the disease. against COVID-19.* The quality outbreak, some smokers may have However, given smokers are more of the data and data analysis recently stopped smoking when likely to present with respiratory have been a major concern in they began to feel ill and reported symptoms like coughing, they are these investigations, as well as that they no longer smoke. also more likely to be tested as the conflict of interest inherent in suspected cases. If proportionately some of the researchers involved Representativeness more smokers take the test than in these studies. While research is of study populations non-smokers, it will appear that still ongoing to better quantify the smokers have a lower risk of risk of acquiring COVID-19 as a Many of the studies informing contracting COVID-19, whether smoker, it is important to recognize our understanding of the link true or not. that there are many challenges between smoking and COVID-19 associated with interpreting these were conducted on selected In order to overcome these potential data, especially at a time of global populations, such as health-care sources of bias, the best study emergency (130, 152). Here are workers or people with design is a large prospective cohort some key challenges: co-morbidities. These populations study that follows a population can exhibit very different smoking that is representative of the Self-reported tobacco prevalence trends compared to general population over time use in hospital settings the general population. People (and for whom we have complete who are admitted to hospital are data on smoking history as well At the start of the pandemic in also often not representative of as confounders such as age and particular, smoking status was the overall population. There are a other underlying conditions) to rarely reported in published number of factors that may make see if they contract COVID-19 reports from clinical settings. them different from the general or not, and to what degree of Self-reported tobacco use is population. For example, people severity. At the time of writing, difficult to collect, particularly in admitted to hospital with COVID-19 the evidence is not conclusive emergency settings. In the hospital during the first wave were more with regards to the relationship setting, where people are admitted likely to be older and suffer from between smoking and the risk in varying states of health, the underlying noncommunicable of contracting COVID-19 (153). collection of smoking status is not diseases. It is also likely that these often high on the priority list for people have better access to health-care workers and if the hospital, whether by virtue someone is unconscious upon of geography or socioeconomic admission, this data may never be context. Importantly, the collected. Information about past majority of studies examining the smoking status and time since association between smoking and quitting is often not collected and
* Investigative journalists have revealed that authors of some controversial papers suggesting smokers are less likely to get COVID-19 are linked with the tobacco industry. One notable paper claiming was retracted from the European Respiratory Journal because of undisclosed conflicts of interest with the tobacco industry among the authors (154).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 53 imposed in many parts of the country the number of cigarettes smoked per COVID-19 drives bold (158). At the same time Bhutan, a day (162). Globally, the impact of the tobacco-control measures country that has maintained a tobacco pandemic on smoking behaviour seems ban for over a decade, lifted the ban to to have varied greatly for different Since the start of the COVID-19 discourage cross-border transmission populations. Some people have pandemic, most governments have and sold tobacco through state-owned reported smoking more than usual to attempted to restrict movement and retailers (159). reduce stress or loneliness at home slow the spread of the disease through (163, 164). At the same time, some Some of these actions provided actions such as curfews, quarantines, studies show that there has been a important lessons for tobacco control and stay-at-home orders. Under these record number of smokers trying to quit going forward. A study conducted conditions, some countries have applied as a result of the COVID-19 pandemic on the South African ban, for “essential goods lists” to restrict the and awareness of the link between example, suggested that without sale of some products and thus limit tobacco use and developing worse implementing other coordinated the movement of people in public symptoms of COVID-19 (165). tobacco control measures, sales bans areas. In a small number of countries may not successfully reduce tobacco these lists have also been used to use (160) and the noncompliance of restrict access to unhealthy products, “vape” shops to non-essential item like tobacco and nicotine products. Cessation services vital as closure orders in the United States COVID-19 prompts people meant that as many e-cigarette users stockpiled these products as those that to quit Bans and restrictions on tried to reduce or quit them (161). As a result of the COVID-19 pandemic, tobacco sales and use, more people may be thinking about applied in some countries their health and potentially thinking Impact of COVID-19 about quitting tobacco. Cessation South Africa and Botswana, for on smoking behaviours services – already insufficient or example, took the opportunity to unavailable in much of the world – designate tobacco and nicotine is mixed have been further neglected during products as non-essential goods, the pandemic and are unlikely to be These country actions represent thereby imposing a temporary ban prioritized for funding during the unprecedented steps to mitigate the on their sale (155). Other countries COVID-19 economic recovery. For impact of tobacco on the vulnerability restricted the use of tobacco in this reason, WHO and partners have of populations and have likely had particular places, such as Spain, aimed to focus more attention on both positive and negative impacts which extended smoking bans to helping people quit. In 2021, WHO on tobacco control. In South Africa outdoor areas (156), and 15 countries launched several innovative initiatives for example, evidence compiled on in the Middle East, where the use of including the World No Tobacco Day the impact of the temporary tobacco waterpipes in indoor areas was banned campaign “Commit to Quit” to help sales ban suggests that many smokers (157). In India, spitting bans (an act encourage people to give up tobacco. attempted to quit smoking or reduced associated with chewing tobacco) were
While the COVID-19 pandemic highlighted the vulnerability of the world’s population, the tobacco and e-cigarette industries exploited the context for their own commercial ends.
54 | WORLD HEALTH ORGANIZATION Commit to Quit! The World No Tobacco Day Campaign
Recognizing that many smokers who want to quit do not have access to appropriate support and that the pandemic has given more people a reason to try quitting, WHO has developed a number of new initiatives to help encourage people to successfully quit tobacco. These initiatives include smoker’s diaries, innovative chatbots and “Meet Florence”, the first artificial intelligence quit-tobacco initiative. The World No Tobacco Day Campaign, typically a 24-hour effort to increase awareness about a particular aspect of tobacco control, was adapted into a year-long campaign in 2021 to reach out globally and help get 100 million people to try to quit tobacco.
Tobacco industry tactics during COVID-19
While the COVID-19 pandemic ■ Attempting to gain a voice in ■ Using social media posts to promote highlighted the vulnerability of the scientific debates. For example, the use of ENDS and other products world’s population to severe respiratory involvement in research as ideal companions for those infection, the tobacco and e-cigarette conducted on tobacco-plant working from home. industries found a number of ways vaccine development positions ■ Making claims about the health to get around public health measures the tobacco industry as being benefits of ENDS. For instance, US that restricted access to non-essential “part of the solution”. Bidi Vapor claimed on Instagram products and exploited the context for ■ Producing promotional material that that “A bidi stick a day keeps the their own commercial ends. The STOP appears almost identical to official pulmonologist away”. initiative at the University of Bath has public health communications from systematically documented cases of ■ Policy interference by challenging health authorities. industry interference since the start of classifications of “essential” the COVID-19 pandemic. Here is a list of ■ Widely distributing promotional businesses to ensure their businesses some of the tactics they have identified: merchandise such as masks with were not negatively impacted. industry logos. ■ Donations to countries portrayed ■ Policy interference by lobbying as corporate social responsibility ■ Offering significant discounts governments to reopen tobacco/ (CSR). In Greece, for example, amid and promotions for e-cigarette cigarette factories early in the findings that smoking predisposes “contactless delivery” and kerbside pandemic in countries including people to more severe outcomes of drop-off locations. Bangladesh, Indonesia, Pakistan and COVID-19, Philip Morris International Russian Federation. This resulted ■ The use of contactless delivery, donated several ventilators to ICUs. in the deaths of two workers in which can undermine “minimum The industry further promoted Indonesia from COVID-19. age of purchase” restrictions, these actions as socially responsible and the waiver of ID validation ■ The tobacco industry has also been actions on their websites and in requirements at the point of delivery using the impact of the pandemic presentations to their shareholders, of HTPs in at least one country. to undermine pending tobacco while remaining silent on the direct control measures. In Europe, ■ Appropriation of the “Stay at harms of using their products. for example, tobacco industry home” social media hashtag (which representatives have used the was used by government and public pandemic to postpone a ban on health officials) to promote heated the sale of menthol cigarettes. tobacco products and ENDS.
Sources: (154, 166–168)
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 55 The tobacco control community can learn a number of lessons from the COVID-19 pandemic experience
Here are just some examples of lessons learned:
■ The importance of providing illness. Tobacco is a key risk factor ■ The need to stay alert to reliable and evidence-based for many NCDs, but stronger tobacco industry interference: information on harms to the tobacco control measures can The tobacco industry and related public: Smoking is a known risk help to meaningfully protect nicotine industries are relentlessly factor for lung and heart health people from its adverse effects opportunistic. Even at a time of and it is important to warn people in the future. In particular, higher crisis they have found ways to of the potential harm it may cause tobacco taxes could play a market their products and get in a new, infectious disease that central role as a potential way to around restrictions intended to affects these organs. Where the generate much-needed revenue protect people’s health. Countries, relationship between tobacco for governments during the corporations and individuals use and COVID-19 is under post-pandemic economic recovery. must remain vigilant against the investigation, it is imperative that industries’ tactics. ■ The importance of promoting robust methodologies and analytical responsible journalism and ■ The importance of approaches are applied to ensure countering misinformation: strengthening cessation that strong and reliable evidence are The media must take responsibility services: The COVID-19 pandemic used to guide appropriate action. for ensuring that trustworthy and has heightened awareness of health ■ The need to “build back better”: reliable information is made readily issues and this may encourage COVID-19 has taken a huge available to the public. Given the some people to try to quit tobacco toll on health and economic many unknowns, the pandemic use. Potential quitters will be more well-being and we now know that has seen a big increase in the rapid likely to succeed if they have the many NCDs make people more online publication of research appropriate support. Nicotine vulnerable to its most serious studies highlighting research results replacement therapies, such as gum consequences. Tobacco control that have not been adequately and patches, and proven cessation is a cost-effective way to improve peer-reviewed. This must be services such as brief advice population health. As countries avoided. Policies and legislation administered by trained health-care go through economic challenges should also be developed to workers, toll-free quit lines and and health systems struggle to manage information on social media mobile text-messaging programmes address the pandemic, tobacco platforms and counter the impact should be made available to all, and control remains an important of misinformation and information strengthened globally. investment that can help prevent overload (“infodemics”). millions of deaths and much
Botswana intensifies tobacco control during COVID-19 pandemic
Botswana issued landmark COVID-19 pandemic emergency Botswana asked citizens to take emergency COVID-19 regulations lockdown – a move that has been care of their health during the in 2020 to prohibit the import and lauded by many as a bold step COVID-19 emergency, saying: “Do sale of tobacco and tobacco-related in placing the interests of public not drink or smoke and keep at products during the pandemic. health above those of business least two meters away from others Parliament’s approval of Statutory and trade. It also affirms the and avoid handshakes.” He also Instrument No. 61 of 2020 made commitment of the government of advised people to stay at home, Botswana the second country Botswana to make health a right wash their hands regularly with in Africa (after South Africa) to for every citizen. soap and water, cough or sneeze prohibit the sale of tobacco and into the inner flexed elbow and Through social media, Facebook tobacco products during the keep their families safe. and Twitter, the President of
56 | WORLD HEALTH ORGANIZATION Fifteen Eastern Mediterranean Region countries ban waterpipe use
Curbing waterpipe use became In response, the WHO Office for temporary bans on waterpipe use a major focus of tobacco-control the Eastern Mediterranean Region in all indoor and outdoor public experts and advocates in the worked closely with Ministries of places, joining two countries Eastern Mediterranean Region Health of countries in the Region that had already implemented after mounting research showed to encourage bans on waterpipe permanent waterpipe bans (Iran the links between tobacco use and use in all indoor and outdoor public (Islamic Republic of) and Pakistan). increased vulnerability to COVID-19. places. By April 2021, 15 countries The ban represents a unique The communal nature of waterpipe and territories (Bahrain, Egypt, and important success for global smoking (in which a single Iraq, Jordan, Kuwait, Lebanon, tobacco control. It shows that mouthpiece and hose are often occupied Palestinian territory, tobacco control policies, in this shared between users in social including east Jerusalem1, Oman, case smoke-free laws, are feasible gatherings) clearly counteracts the Qatar, Saudi Arabia, Sudan, Syrian and effective, even with strong social distancing measures essential Arab Republic, Tunisia, United Arab resistance from governments and to limiting the spread of COVID-19. Emirates, and Yemen) adopted the tobacco industry.
1 “occupied Palestinian territory” is also employed throughout the report to refer to “occupied Palestinian territory, including east Jerusalem”
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 57 58 | WORLD HEALTH ORGANIZATION EFFECTIVE TOBACCO CONTROL MEASURES
m Monitor tobacco use and prevention policies
p Protect people from tobacco smoke
o Offer help to quit tobacco use
w Warn about the dangers of tobacco
e Enforce bans on tobacco advertising, promotion and sponsorship
r Raise taxes on tobacco
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 59 MONITOR TOBACCO USE AND PREVENTION POLICIES
Article 20 of the WHO FCTC states: “…Parties shall establish …surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at the regional and international levels…” (174)
Monitoring strengthens tobacco control
Monitoring patterns and trends in Key products to track include: In addition to monitoring the impact tobacco use and exposure are key to of tobacco control policy interventions ■ cigarettes and other forms of combatting the tobacco epidemic and (169), it is important that tobacco smoked tobacco (e.g. cigar, strengthening the WHO FCTC – one industry activities are monitored pipe, bidis, water pipe, heated of the Sustainable Development Goals and tracked when feasible (170, tobacco products); (SDG 3.a). Reliable, timely data is 171). Such data can help adjust and critical to understand both the unmet ■ smokeless tobacco products enhance tobacco control strategies. need for tobacco control measures (oral or nasal tobacco); and the effects of tobacco control ■ novel and emerging tobacco measures already in place. Data gives products such as tobacco vaporizers; policy-makers the evidence they need and to advocate for more tobacco control efforts and implementation resources. ■ non-tobacco forms of nicotine (e.g. ENDS). Monitor the prevalence of tobacco use
MONITORING THE PREVALENCE OF TOBACCO USE – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries with the highest level of achievement: Armenia, Australia, Austria, Azerbaijan, Bahamas, Bangladesh, Belgium, Bhutan, Brazil, Brunei Darussalam, Bulgaria, Cambodia, Canada, Chile, *China, Cook Islands, Costa Rica, Croatia, Cyprus, Czechia, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Indonesia, Iran (Islamic Republic of), Ireland, Italy, Japan, Kazakhstan, Kuwait, Lao People’s Democratic Republic, Latvia, Lebanon, Lithuania, Luxembourg, Malaysia, Malta, Mongolia, Montenegro, Myanmar, Netherlands, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Philippines,The designations Poland,employed and Portugal, the presentation Qatar, of the Republic material in of this Korea, publication Republic do not imply of theMoldova, expression ofRomania, any opinion whatsoeverRussian onFederation,Data Source:Serbia, WHO Singapore, Slovakia, Slovenia, Spain, Sweden, the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre Switzerland,frontiers or boundaries. *Tajikistan, Dotted and Thailand,dashed lines on Turkey, maps represent Ukraine, approximate United border Kingdom, lines for which United there mayStates not yet of be America, full agreement. Uruguay,for Viet Health, Nam. DNA/DDI © WHO 2021. All rights reserved. * Country newly at the highest level since 31 December 2018.
60 | WORLD HEALTH ORGANIZATION Increases in global coverage of MPOWER measures since 2007 has helped reduce the global rate of tobacco smoking from 22.7% to 17.5% in 2019.
population over the last 5 years. For countries joining the best-practice Half the world is covered the first time in this report, however, group were China and Tajikistan. one low-income country has joined by strong tobacco use Owing to the challenges of running the group of countries that monitor at monitoring systems national population-based surveys best-practice level (Tajikistan). No recent during the COVID-19 pandemic, surveys (since 2014) were completed Over half of the world’s population many surveys planned in 2020 were in a total 37 of the world’s countries. – 4.4 billion people in 78 countries delayed or cancelled. Further, the – live in countries with strong results from some surveys undertaken monitoring systems that include in 2019 were not released in time recent, representative and periodic Ongoing monitoring of for this report. This situation led to population-based surveys and school- tobacco use is a challenge 11 countries at best-practice level in based surveys which ask adults and 2018 being unable to maintain the adolescents about tobacco use. Most for some countries achievement. Consequently, these of these countries (46 out of 78) with 11 countries (Bahamas, Bangladesh, comprehensive monitoring are high- Since 2018, the number of countries monitoring at best-practice level Bhutan, Cambodia, Costa Rica, Egypt, income countries. Despite having Kuwait, Myanmar, Pakistan, Panama, adequate resources, 25% of high- has increased from 76 to 78. The population living in countries who Qatar), with 577 million people, have income countries have not completed exceptionally been retained in the monitoring of tobacco use within their monitor at best-practice level increased from 3 billion to 4.4 billion. The two best-practice group in this report.
Investing in regular surveys and other measures reduce tobacco use, Tajikistan
Since 2004, Tajikistan has The second round of the STEPS smoking and nasvai tobacco use (a conducted several national surveys survey is being planned and will form of smokeless tobacco) by 2023. to monitor progress on tobacco provide an opportunity to monitor Reaffirming the country’s control, including Demographic and in-country trends in tobacco use commitment to tobacco control Health surveys in 2012 and 2017; among adults. Furthermore, the and benefiting from the political a Global Adult Tobacco Survey in fourth round of GYTS is planned will generated by the evidence 2016; the WHO STEPwise Approach for 2024, demonstrating Tajikistan’s from prevalence surveys, Tajikistan to Noncommunicable Disease strong commitment to monitor became a Party to the WHO FCTC Risk Factor Surveillance (STEPS) in tobacco use by collecting recent, in 2013, and in 2018 passed a 2016–17; a Global School-Based representative and periodic data strong new tobacco control law. Student Health Survey in 2006 for both adults and youth. The new law applies to all tobacco and Global Youth Tobacco Survey To address the issue of tobacco use, products, including cigarettes (GYTS) in 2004, 2014 and 2019. the National Strategy for Prevention and cigars as well as hookahs, The results of the adult surveys and Control of Noncommunicable smokeless tobacco, cigarettes and conducted throughout this diseases and Injuries in the Republic electronic cigarettes, and contains period show that the tobacco use of Tajikistan 2013–2023 includes effective tobacco control measures prevalence rate is moderate to the target of a 20% reduction in in line with the WHO FCTC. high among men and very low in women (13.5% in total – 25.7% among men and 0.2% among women). The smokeless forms of tobacco appear to be the main area of concern requiring attention, with 10.3% of the population overall and 19.7% of men using smokeless tobacco (172). Students in Tajikistan fill out the Global Youth Tobacco Survey in 2019
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 61 MONITORING (2020)
100% 3 No known data, or 90% 17 no recent data or data 8 that are not both recent 80% 4 and representative 70% 17 33 Recent and representative 60% data for either adults or adolescents 50% 46 40% 24 Recent and representative data for both adults and 30%
Proportion of countries adolescents 10 (Number of countries inside bars) 20% 31 Recent, representative and 10% 1 periodic data for both 0% 1 adults and adolescents High-income Middle-income Low-income
PROGRESS IN MONITORING (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 4.4 100 81 77 76 78 70 3 3.2 Number of countries 62 3.0
Population protected (billions) Population 52 2.7 2 50 38 2.1 1.9 1.7 1.5 1 PROGRESS IN MONITORING (2007–2020) 0 0 2007 2008 2010 2012 2014 2016 2018 2020 100% 3 No known data, or Population (billions) 90% Countries 17 no recent data or data 8 that are not both recent 80% 4 and representative
70% 33 17 Since 2007, 2.9 billion people in 40 one national survey among adults or monitoring. If those Recent29 countries and representative closed 60% data for either adults additional countries have become adolescents in the past 5 years. However, the gap to meet best-practiceor adolescents level there newly covered by tobacco use only 40%50% of low-income countries would be an addition 1.8 billion people 46 monitoring at best-practice level. (12 countries)40% have done so. In 2020,24 (23% of the world’sRecent population) and representative living in there was a total of 117 countries not countries that ensuredata effective for both monitoring adults and Ninety-five percent of high-income 30%
Proportion of countries adolescents monitoring their tobacco epidemic at the of10 the tobacco epidemic to better inform countries and 80% of middle-income (Number of countries inside bars) highest20% level, however, 29 were just one policy measures going forward. countries have completed at least 31 Recent and representative step away10% from a comprehensive level of 1 and periodic data for both 0% 1 adults and adolescents High-income Middle-income Low-income 62 | WORLD HEALTH ORGANIZATION Surveys play a strong role in informing tobacco policy development, China
China is the world’s largest producer the time of the survey, China’s challenging: data collectors have and consumer of tobacco products national Advertising Law was being struggled to reach households in and is home to more than 300 amended, and the results provided remote areas and sometimes spend million smokers (a quarter of the strong evidence for the promotion several days visiting people’s homes global total). Each year more of relevant provisions to strengthen to complete the questionnaires. than 1 million people in China die the regulation of tobacco However, robust research design has from diseases caused by tobacco advertising in public places. In 2019, ensured that data are successfully (91, 173). To monitor the tobacco China implemented a second round gathered and are nationally epidemic, China regularly conducts of GYTS, which showed that the representative. With China achieving nationally representative tobacco use of ENDS among adolescents the MPOWER best-practice level use surveys. was increasing. The data from for monitoring tobacco use, 1.4 these surveys were used by public billion more people are now covered China undertook the Global Adult health organizations to advocate in by nationally representative and Tobacco Survey in 2010. The survey the National People’s Congress for periodically collected data that results provided important data to provisions related to e-cigarettes in help fight the tobacco epidemic. promote tobacco control policies the “Minors Protection Law”. China aims to continue to improve in China, such as raising tobacco its tobacco surveillance system to taxes and tobacco advertising, Because of its vastness and diversity, strengthen tobacco control and promotion and sponsorship bans. national surveillance in China is reduce tobacco use. The results were also used to raise awareness in the general public through news stories and social media content, and to inform policy proposals highlighting the urgency for tobacco control.
To determine the seriousness of the tobacco problem among young people, China conducted the first round of a Global Youth Tobacco Survey (GYTS) in 2013–2014. At Tobacco use survey reports from China
still have the highest average smoking Over one billion people Smoking rates are rate of all income groups in 2019 smoke, less than 100 million declining globally (21.6%). During this same decade, fewer than in 2007 smoking among men decreased from Between 2007 and 2019, smoking 37.5% to 29.6%, and smoking among In total, there are almost one billion rates decreased from a global average women decreased from 8.0% to tobacco smokers aged 15 years and of 22.7% to 17.5%, showing a relative 5.3%. In 2019, smoking rates among above worldwide. This number has reduction of 23% over 12 years. women in high-income countries are changed little since 2007 when there Smoking rates in low-income countries still the highest of all country income were just over one billion tobacco are about half the rate of rates in groups (16.4%) – more than four smokers. Currently, 847 million men high-income countries, and this ratio times the average rate in low- and smoke tobacco (46 million fewer than has changed little over the period. middle-income countries (3.5%). In in 2007) and 153 million women (36 The relative reduction of the smoking contrast, the highest rates among million fewer than in 2007). rate between 2007 and 2019 in high- men are seen in middle-income income countries was 20%, and in countries (35.3%), where it is almost Despite three out of four countries low-income countries 19%. In middle- double the average rate found in banning sales to minors under the age income countries (in which three- low-income countries (20.2%). of 18 years – and another 10 countries quarters of the world’s population lives) Currently there is no global estimate setting an even higher age limit for the relative reduction was only 12%. tobacco purchases – an estimated 24 of ENDS use because the data are still million children aged 13–15 around While smoking rates are declining scant in many regions of the world. the world smoke, and 13 million use fastest on average in high-income smokeless tobacco (91). countries, these countries collectively WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 63 PROTECT PEOPLE FROM TOBACCO SMOKE
Article 8 of the WHO FCTC states:
“… [S]cientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability … [Parties] shall adopt and implement … measures providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”.
WHO FCTC Article 8 guidelines are intended to assist Parties in meeting their obligations under Article 8 of the WHO FCTC and provide a clear timeline for Parties to adopt appropriate measures (within 5 years after entry into force of the WHO FCTC for a given Party) (174).
rooms are indeed smoke-free and The harms of protect non-smokers from second-hand Smoke-free laws do not second-hand smoke smoke. Such exceptions – designated hurt business smoking areas or rooms, ventilation There is no safe level of exposure systems, air exchanges, and filtration In spite of tobacco industry assertions to second-hand smoke, and even devices – are not protective, and to the contrary, the best-designed brief exposure can cause harm (175). cannot eliminate all second-hand studies report that smoke-free Severe or fatal diseases, including smoke (41, 186, 187). Indeed, such laws have no adverse economic heart disease, respiratory disease, and accommodations weaken the impact consequences for businesses, including cancer (41, 176, 177) can result from of smoke-free laws. The only way to the hospitality industry (196–198). In exposure to second-hand smoke – and fully protect people from second- fact, when applied, smoke-free laws non-smokers living with smokers are hand smoke is to permit no exceptions invariably receive overwhelming public at greater risk of such diseases, and (187–189). This is because, when fully support (191, 199) and encourage premature death (178). Children and implemented, smoke-free laws are families with children to visit and infants are particularly susceptible and highly effective in decreasing exposure consume in places previously avoided at increased risk for respiratory disease, and enhancing indoor air quality for by them. Smoke-free laws are relatively middle-ear disease, and sudden infant both smokers and non-smokers easy to pass and economically and death syndrome (179 –184). Pregnant (186, 190, 191). politically feasible to enforce, and women exposed to second-hand smoke an increasing number of countries are more likely to experience stillbirths, continue to adopt comprehensive and their fetuses are more likely to have smoke-free legislation at national and congenital malformations and lower The wider benefits of subnational level. birth weights (184). The only way to smoke-free laws are adequately protect both smokers and far-reaching non-smokers from second-hand smoke Still, only 34% of countries is to fully eliminate indoor smoking There is robust evidence that public (178). For example, an analysis based spaces with smoke-free laws see and 24% of the world’s on data from Brazil suggested that, reduced hospital admissions for acute population are protected over a period of 16 years, up to 15 000 coronary syndrome and reduced by complete smoking bans infant deaths may have been averted by mortality from smoking-related illnesses the implementation of comprehensive (187). Smoke-free laws make smoking There has been sustained progress in smoke-free laws (185). less acceptable, less visible to children the adoption of smoke-free laws since and youth, and encourage healthier 2007, when only 10 countries in the behaviours such as not smoking in the world had a comprehensive smoking Smoke-free must mean home or in the car (192–194). Smoke- ban in place, covering just 3% of the free environments may also encourage world’s population. Since then, 1.6 completely smoke-free smokers to reduce their tobacco use, billion additional people in 57 additional make a quit attempt, and remain countries are now covered by best- It is a misconception that smoke-free tobacco-free in the long-term (191, 195). practice smoke-free laws. This means places that allow designated smoking
64 | WORLD HEALTH ORGANIZATION Smoke-free environments
SMOKE-FREE ENVIRONMENTS – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries and areas with the highest level of achievement: Afghanistan, Albania, Antigua and Barbuda, Argentina, Australia, Barbados, Benin, *Bolivia The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO (Plurinationalthe part of WHO concerning State of),the legal Brazil, status Brunei of any country, Darussalam, territory, city Bulgaria, or area or of Burkina its authorities, Faso, or concerningBurundi, the Cambodia, delimitation of Canada,its MapChad, Production: Chile, WHO Colombia, GIS Centre Congo, Costa Rica, Ecuador, Egypt, frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI El Salvador, *Ethiopia, Gambia, Greece, Guatemala, Guyana, Honduras, Iran (Islamic Republic of), Ireland, Jamaica, *Jordan, Lao People’s Democratic© WHO Republic, 2021. All rights reserved. Lebanon, Libya, Madagascar, Malta, Marshall Islands, Namibia, Nauru, Nepal, New Zealand, Niue, North Macedonia, Norway, occupied Palestinian territory, Pakistan, Panama, Papua New Guinea, *Paraguay, Peru, Romania, Russian Federation, *Saint Lucia, Seychelles, Spain, Suriname, Tajikistan, Thailand, Trinidad and Tobago, Turkey, Turkmenistan, Uganda, United Kingdom, Uruguay, Venezuela (Bolivarian Republic of). * Country newly at the highest level since 31 December 2018. that there are now 1.8 billion people (a countries (Bolivia (Plurinational State people only need to cover two more quarter of the world’s population) living of), Ethiopia and Jordan) advanced places with a smoke-free ban to reach in 67 countries where the smoking bans from three to five public places covered best-practice adoption. are at best-practice level. by comprehensive smoke-free bans, Six countries (with 260 million people and one country (Paraguay) extended While around one third of countries in total) improved their smoke-free law the smoke-free ban to two additional in each income group are covered by since 2018 but did not reach best- places (restaurants and cafés/pubs/ comprehensive smoke-free bans, more practice level in 2020. Fourteen countries bars) to reach best-practice level. than half of these countries (39 of 67 (with 1.6 billion people in total) would countries) with comprehensive smoking achieve a comprehensive ban by simply bans in 2020 were middle-income removing the allowance of designated countries. The complete absence of 37% of countries, and smoke rooms under the law. smoking bans, or minimal bans that are 38% of the world’s Of the 524 million people (6.7% of not comprehensive enough to protect the world’s population) who live in one people from the harms of second-hand population, have partial of the world’s 100 largest cities, only smoke, are remarkably common in smoking bans that fall 299 million (in 47 cities) are protected high-income countries. In fact, 18 high- short of best practice by a comprehensive smoke-free law. income countries (30%) are leave their Five of these cities (Bandung, Beijing, populations exposed to second-hand There are 12 countries, representing Hong Kong SAR, Jakarta and Medan) smoke in public places. The same is true 124 million people, that only need to are covered by city-level smoke-free for 25 middle-income countries (22%) cover one more place with a smoking laws; seven are covered by state- or and 13 low-income countries (45%). ban to join the 67 other countries province-level smoke-free laws; and the with comprehensive smoke free laws: In the past 2 years, five countries have remaining 35 are covered by national Tonga (universities); Democratic joined the group of countries providing laws. Instead of waiting for national People’s Republic of Korea (government protection at best-practice level, with legislation to be adopted, the remaining facilities); Cook Islands, Mauritius, all public places completely smoke-free. 52 of the world’s largest cities not Ukraine and Zambia (indoor offices); One of these countries (Saint Lucia) currently protected by a national best- Senegal (restaurants); Bhutan (cafés, went from a minimal law covering practice law could move ahead with a pubs, bars); and Armenia, Cyprus, only health care and governmental city, state or provincial level law to more Georgia and Hungary (public transport). facilities to a complete ban covering all swiftly protect their large populations. A further 17 countries with 1.6 billion public places and workplaces. Three
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 65 Comprehensive smoke-free legislation is in place in one third of countries.
SMOKE-FREE LEGISLATION (2020)
100%
90% 25 Data not reported 18 80% 13 Complete absence of ban, or up 70% to two public places completely 24 smoke-free 60% 15 Three to five public places 50% 4 17 completely smoke-free 40% 9 3 Six to seven public places 30% completely smoke-free Proportion of countries (Number of countries inside bars) 20% 39 All public places completely 19 9 smoke-free (or at least 90% of the 10% population covered by complete 0% subnational smoke-free legislation) High-income Middle-income Low-income
PROGRESS IN SMOKE-FREE LEGISLATION (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 100
3 67 Number of countries 62 56 Population protected (billions) Population 51 2 45 50 32 1.8 1.6 1.6 1.7 1 15 1.3 10 0.9 0.4 0 0.2 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
66 | WORLD HEALTH ORGANIZATION Ethiopia hospitality sector goes smoke-free
In February 2019, Ethiopia passed a enforcement of the smoke-free smoking” signs and verbally during law requiring public buildings and regulation nationwide. EFDA raised reservation and at check-in that that workplaces (including hotels) to be awareness of the new law among smoking is prohibited within the 100% smoke-free (Proclamation No. staff nationally and locally, and hotel and its premises. No designated 1112/2019). The law bans smoking introduced and promoted the new smoking rooms or areas, or ashtrays, or tobacco use in any indoor and law among stakeholders, including are available. Hotel staff have outdoor space within 10 metres of hotels and resorts in Addis Ababa. welcomed the new law because it any doorway, operable window, or Orientation workshops outlining the protects both customers and staff. air-intake mechanism of any public roles and responsibilities of hotel place or workplace. or resort owners were organized. More than 15 000 “No smoking” The hospitality sector has some stickers and 3000 posters were of the greatest levels of exposure printed and disseminated. These to second-hand smoke, which capacity-building activities were means that if Ethiopia’s smoke-free followed by compliance inspections. law enforcement and compliance More than 16 000 inspections by is to be effective, this sector regulators of a variety of public needs to be fully on board. In places across the country have been 2019, the Ethiopian Food and reported since 2019. Drug Administration Authority (EFDA) – mandated to enforce After the new proclamation, and coordinate implementation of many hotels made huge efforts to tobacco control activities in Ethiopia implement the 100% smoke-free – undertook measures to scale up law. Customers are informed by “no No Smoking sign in hotel lobby, Addis Ababa
Paraguay bans smoking in indoor public spaces spurred by COVID-19 evidence
An estimated 5000 people died Decree 4624 in December 2020 from tobacco-related diseases in established that smoking traditional 2019 in Paraguay, with almost 700 (cigars, cigarettes), heated, or of these deaths associated with electronic tobacco products would exposure to second-hand smoke be permitted only in uncrowded (200). The impact of tobacco use on open-air public spaces that are the health of Paraguay’s population not transit areas for non-smokers. has been further highlighted This closed the country’s previously during the COVID-19 pandemic, as remaining gap, which allowed evidence showed that tobacco users smoking areas in enclosed, were more likely to suffer severe hospitality spaces. consequences of the disease. In fact, By making all indoor public spaces the link between COVID-19 and and workplaces, as well as public tobacco use was part of the rationale transport completely smoke-free, behind strengthening tobacco the decree brings Paraguay into control in Paraguay during 2020. compliance with a central mandate Since Paraguay ratified the WHO of the WHO FCTC: to protect FCTC in 2006 the country has populations from the harmful embarked on ensuring that its effects of tobacco. Simultaneously, tobacco control policies align with the passage of this regulation made the Convention. After several failed South America the first sub-region attempts to adopt a complete in the Americas to become entirely smoke-free law, the passing of 100% smoke-free. No smoking and no e-cigarette use signs in Paraguay
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 67 OFFER HELP TO QUIT TOBACCO USE
Article 14 of the WHO FCTC states:
“Each Party shall … take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence… . Each Party shall … design and implement effective programmes aimed at promoting the cessation of tobacco use”. WHO FCTC Article 14 guidelines are intended to assist Parties in meeting their obligations under Article 14 of the WHO FCTC) (174).
worker to offer or provide them with The desire to quit is strong, Support is vital to quitting personalized counselling. This “brief advice” from health professionals – but help is too scarce Nicotine is so addictive that a quarter given as part of a routine consultation of teenagers can become dependent Tobacco control policies in many or interaction – makes efficient use of upon it after smoking just three or countries have successfully motivated the existing health-care system (205). people to make quit attempts. On four cigarettes, and after smoking Toll-free quit lines are another average, across countries where the five packs, nearly 60% are dependent convenient way for potential tobacco Global Adult Tobacco Survey has been (202). Most people who use tobacco quitters to access brief and potentially conducted, over 60% of smokers regularly do so because they are intensive behavioural counselling. indicated that they intend to quit, and addicted to nicotine. This means they Those that use quit lines increase their over 40% had attempted to quit in the can therefore benefit greatly from a absolute quit rate by 4 percentage 12 months preceding the survey. While range of effective tobacco cessation points, which represents a doubling this is encouraging, support for quitting interventions. Without cessation of success compared to those who remains low (91). assistance, only around 4% of attempts to quit tobacco are successful (203). attempt to quit without assistance (204). This rate can be further increased Proven cessation medications and if the quit line is “proactive” and professional support can double a Quitting tobacco has counsellors make follow-up calls to tobacco user’s chance of successfully potential tobacco quitters. Recent instant benefits quitting (204) and a number of app-based interventions for cessation different approaches have been The health benefits of quitting smoking are promising, with text message developed to help people succeed. can be felt within hours or even minutes. interventions increasing the absolute These can broadly be categorized In just one day, quitting tobacco can help quit rate by 4% (206). reduce a person’s heart rate and blood as behavioural or pharmacological pressure, and blood carbon monoxide interventions, and differ in terms of Pharmacological interventions levels can be expected to return to normal their intensity, cost and effectiveness. are diverse and can work Combining both behavioural and (201). Within 3 months of quitting, better in combination circulation and lung function improves, pharmacotherapy interventions is The effectiveness of pharmacotherapies and within 1–9 months, coughing and more effective and can double the to assist quitting tobacco is generally shortness of breath generally decrease chances of successfully quitting (a 70% higher compared to people who did (201). The risk of death due to tobacco to 100% relative increase compared not use an intervention. The quit use also begins to decrease soon after to brief advice or support) (205). rate increase ranges from 6% for a quitting. The risk of death from lung single type of NRT to almost 15% for cancer is reduced by 30–50% within Behavioural interventions Varenicline. Pharmacotherapy cessation 10 years of quitting smoking (201), with are efficient and present interventions include NRTs, as well as current evidence suggesting that the risk an opportunity to reach medications that do not contain nicotine of death from ischemic heart disease is potential quitters but act to alleviate tobacco withdrawal halved within 5 years of quitting, and the When a tobacco user visits a primary symptoms. Combining more than one risk of stroke returns to that of a never or specialized care service it presents NRT (patches and a faster-acting form) smoker within 5–15 years. an opportunity for the health-care can also increase NRT effectiveness.
68 | WORLD HEALTH ORGANIZATION Tobacco dependence treatment
TOBACCO DEPENDENCE TREATMENT – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
CountriesThe designations with employed the highestand the presentation level of of achievement: the material in this *Austria, publication do Brazil, not imply Canada, the expression *Cook of any Islands, opinion whatsoever Costa onRica, Czechia,Data Source: Denmark, WHO India, Ireland, Jamaica, *Jordan, Kuwait, the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre Luxembourg,frontiers or boundaries. Mexico, Dotted andNetherlands, dashed lines on Newmaps represent Zealand, approximate *Philippines, border lines Republic for which there of Korea,may not yet Saudi be full Arabia, agreement. Singapore,for Health, Slovakia, DNA/DDI Sweden, *Tonga, Turkey, United Arab Emirates, United States of America. © WHO 2021. All rights reserved. * Country newly at the highest level since 31 December 2018.
since 2007, best-practice adoption of Over 30% of the world’s Demand for cessation cessation services nonetheless increased population are covered services is high and from 10 countries (5% of the world’s by comprehensive this must be met population) in 2007 to 26 countries (32% of the world’s population) in cessation services Since 2018, the number of countries 2020 – meaning 2.1 billion additional people are now protected by this As of 2020, comprehensive tobacco offering comprehensive cessation measure. The population offered cessation services are in place for 2.5 services increased from 24 to 26, best-practice cessation services in 2020 billion people in 26 countries – or 32% and the proportion of the world’s is six times what it was in 2007 (when of the world’s population. The number population covered by comprehensive it was only 406 million people). of countries adopting comprehensive cessation services increased from 31% tobacco cessation measures lags behind to 32%. Five countries with a combined Sixty-seven countries – home to 2.2 the other MPOWER measures, with population of 129 million (Austria, billion people – provide cessation only 17 high-income countries and Cook Islands, Jordan, Philippines and support packages that are missing only nine middle-income countries offering Tonga) began offering comprehensive one element to achieve best-practice comprehensive cessation support. No cessation services in the past 2 years. implementation: (i) a national toll-free low-income countries currently offer Disappointingly, however, the number quit line; (ii) cost-coverage of NRT; or best-practice services. of people protected by this has been (iii) cost-coverage of cessation services offset by three countries (Australia, in clinical settings or in the community. Globally, almost all high-income El Salvador and Senegal, representing Of these 67 countries, 26 need to add countries (89%) offer at least partial 48 million people) dropping out of the a national toll-free quit line in order to coverage of the cost of cessation best-practice group in the same period. bring comprehensive tobacco cessation services. Most middle-income countries support to an additional 827 million (72%) do the same, while 18% of Only four high-income countries (7% people, while 38 need to offer cost- low-income countries offer some of the 61 high-income countries) offer covered NRTs to cover an additional cost-coverage for services. There are no support to help users quit, while 12 1.3 billion people. Three countries 32 countries that provide no cessation middle-income countries (11%) and 16 need to cost-cover one or more of its support at all. These numbers show low-income countries (55%) offer no cessation services in clinical settings or that while work has begun, there is still support to tobacco users. the community so that an additional 50 much more to be done. While progress has been slower in million people will be covered. “O” than other MPOWER measures
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 69 Amid significant health-care service disruptions during the COVID-19 pandemic, 120 million additional people now have access to toll-free quit line services and other quitting tools.
Of the 524 million people (6.7% of the of these cities are covered by city-level remaining 52 large cities not currently world’s population) who live in one of policies (Hong Kong SAR and London) protected by a national best-practice the world’s 100 largest cities, only 252 and the remaining 46 are covered by policy could move ahead with a city, million (in 48 cities) are protected by a national policies. Instead of waiting for state or provincial level policy to help comprehensive cessation service. Two a national policy to be put in place, the their large populations sooner.
TOBACCO DEPENDENCE TREATMENT (2020)
100% 1 Data not reported 4 12 90% 3 16 80% None
70% 16 60% 37 NRT and/or some cessation 50% services, neither cost-covered 40% 68 NRT and/or some cessation 30% 7 Proportion of countries services, at least one of which (Number of countries inside bars) 20% is cost-covered 17 10% 5 National quit line, and both 9 NRT and some cessation 0% services cost-covered High-income Middle-income Low-income
PROGRESS IN TOBACCO DEPENDENCE TREATMENT (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 100
3 Number of countries Population protected (billions) Population 2 2.4 2.4 2.5 50
18 19 25 24 26 1 15 16 10 0.8 0.9 0.9 1.0 0.4 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
70 | WORLD HEALTH ORGANIZATION Tonga becomes first Pacific Island Country to offer comprehensive cessation support
Tonga’s smoking prevalence is among A national toll-free quit line, the strong government commitment the highest in the world, with 40% of first of its kind in the South Pacific, and dedicated resources are key to males and 16% of females smoking was launched in 2016 as part of the tobacco cessation. These efforts in 2017 (aged 18 to 69) (207). To campaign. Trained quit line advisors received international recognition address this, Tonga has implemented answer calls Monday to Friday when the Ministry of Health and the laws and policies to reduce the during business hours to provide Tonga Health Promotion Foundation affordability of tobacco; prevent brief counselling support. One in won the World No Tobacco Day tobacco advertising, promotion three tobacco users supported Award in 2018. and sponsorship; expand smoke- through the quit line successfully free public places; and strengthen quit for at least six months. enforcement. These actions have Also as part of the government’s increased the demand for cessation comprehensive programme on services, with 53.9% of male smokers cessation, regular brief tobacco and 62.9% of women smokers intervention trainings are trying to quit smoking at least once conducted for primary health- in the past 12 months (207). care workers throughout Tonga, The Ministry of Health’s “Quit and the government has also Smoking Now”campaign, launched partially covered the cost of in 2016, and delivered through TV, nicotine replacement therapies. radio, social media and outdoor An evaluation in 2017 revealed that signage, focuses on increasing 95% of Tongans between the ages motivation to quit, providing of 18 and 64 were aware of the support to people who want to quit, campaign and awareness of the quit and advocating for stronger policies line increased from 40% to 74% to restrict the sale, distribution and (208). Tonga’s case highlights that Quit line advertisement in Tonga use of tobacco products in Tonga.
Scaling up cessation services in Jordan
With a 41% smoking rate, tobacco with support from the Coalition the country’s primary health-care is the leading risk factor for for Access to NCD Medicines and centres. In addition to this support, noncommunicable diseases (NCDs) Products. The initiative is designed to tobacco users can also freely access in Jordan, causing nearly 17% of all help countries deliver comprehensive WHO’s first virtual health worker, deaths in 2019 (200). According to tobacco cessation services during the Florence, who helps people develop the country’s 2019 STEPS Survey, COVID-19 pandemic. In 2020, Jordan a personalized plan to quit and can about 50% of adult smokers in became the fourth country in the refer them to cessation services Jordan had tried to quit smoking WHO Eastern Mediterranean Region such as the quit line. in the past 12 months, yet only to provide comprehensive tobacco a small percentage of them had cessation services, achieving this access to support to do it (209). through a newly established national toll-free quit line, strengthened In response, the Jordanian Ministry tobacco cessation support in primary of Health greatly scaled up national care, and free access to NRT. tobacco cessation services through its partnership with the Access Jordan also received donated NRT Initiative for Quitting Tobacco, a products to help 5400 frontline joint initiative between WHO, the workers, patients with NCDs, and UN Interagency Task Force on NCD refugees quit smoking, greatly Prevention and Control, and PATH, expanding cessation services in Tobacco cessation consultation in Jordan
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 71 WARN ABOUT THE DANGERS OF TOBACCO
HEALTH WARNING LABELS
Article 11 of the WHO FCTC states:
Each Party shall … adopt and implement … effective measures to ensure that … tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading, deceptive or likely to create an erroneous impression about its characteristics, health effects, hazards or emissions”.
WHO FCTC Article 11 guidelines are intended to help Parties meet their obligations under Article 11 of the WHO FCTC, which provides a clear timeline for Parties to adopt appropriate measures (within 3 years after entry into force of the WHO FCTC for a given Party) (174).
smokeless tobacco use (225). To be Graphic health warning The power of packaging effective they should be large, cover at least half of a package’s surface (front labels are critical Packaging allows companies to “sell” and back) (221), and should refer to their product by manipulating people’s Many tobacco users still do not know, specific health effects from tobacco use. perception of taste, strength, and the or do not fully understand, the dangers To maintain their impact, labels should health impacts associated with it (218). to which they expose themselves and be rotated on a regular basis (226). Over Marketing terms suggesting reduced others by consuming tobacco (210). In time, strengthening the warnings can health risks including “light”, this context, consumers have a right to increase knowledge about the harms of “ultra-light”, and “low tar” are be warned about the health impacts tobacco, and can increase quit attempts deceptive and should be banned (216). of the products they buy and use and reduce cigarette consumption (227). (210–212). Graphic health warnings However, this may not be sufficient to Strong graphic package warnings are provide accurate information about decrease the misperceptions of reduced in place for almost 4.7 billion people the risks associated with tobacco use risk associated with these cigarette types in 101 countries – covering over and can help encourage tobacco users (219, 220). Other requirements, such as half of the global population (60%) to reduce their consumption and quit plain packaging, may help to transform and over half of all countries. More (213, 214). Effective health warnings people’s perceptions. people are protected by this MPOWER can also communicate the risks of Graphic health warnings on tobacco measure than any other, with 52% of exposing others to second-hand smoke product packaging are a reliable way countries adopting graphic warning (215). There is significant evidence that of reaching users with important requirements at the highest level: 69% accurate, prominent warnings prompt information (221) and are a relatively of high-income countries, 50% of tobacco users to think about quitting, cheap public communication method middle-income countries and 24% of and can result in decreased tobacco for governments (221). Graphic health low-income countries. Only 43 countries use (216, 217). warnings are well-supported by the (six high-income, 24 middle-income and public – more than most other tobacco 13 low-income) adopted warnings that control measures (215, 222). cover less than 30% of the pack or have These warnings are most effective when not adopted any warning labels, and 51 pictorial, graphic, comprehensive, and others have issued warnings that cover strongly worded (223, 224), and are 30% but less than 50% of the principal particularly effective in deterring youth package display areas (below the and young adults from cigarette and minimum required by the WHO FCTC).
72 | WORLD HEALTH ORGANIZATION Health warning labels
HEALTH WARNING LABELS – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries with the highest level of achievement: Argentina, Armenia, Australia, Austria, Bangladesh, Barbados, Belarus, Belgium, Bolivia (Plurinational State of), Brazil, Brunei Darussalam, Bulgaria, Burkina Faso, Cambodia, Cameroon, Canada, Chad, Chile, Costa Rica, Croatia, Cyprus, Czechia, Denmark, Djibouti, Ecuador, Egypt, El Salvador, Estonia, *Ethiopia, Fiji, Finland, France, *Gambia, Georgia, Germany, Ghana, Greece, Guyana, Honduras, Hungary, India, Iran (Islamic Republic of), Ireland, Italy, Jamaica, Kazakhstan, Kyrgyzstan, Lao People’s Democratic Republic, Latvia, Lithuania, Luxembourg, Madagascar, Malaysia, Malta, *Mauritania, The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO Mauritius,the part of WHO Mexico, concerning Mongolia, the legal status *Montenegro, of any country, territory, Namibia, city or areaNepal, or of itsNetherlands, authorities, or concerning New Zealand, the delimitation *Niger, of its *Nigeria,Map Production:Pakistan, WHO Panama, GIS Centre Peru, Philippines, Poland, Portugal, frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI *Qatar, Republic of Moldova, Romania, Russian Federation, Saint Lucia, Samoa, Saudi Arabia, Senegal, Seychelles, Singapore, Slovakia, Slovenia, Solomon© WHO 2021. All Islands, rights reserved. Spain, Sri Lanka, Suriname, Sweden, Tajikistan, Thailand, Timor-Leste, Trinidad and Tobago, Turkey, Turkmenistan, Ukraine, *United Kingdom, United States of America, Uruguay, Vanuatu, Venezuela (Bolivarian Republic of), Viet Nam. * Country newly at the highest level since 31 December 2018.
More than half of all countries are now covered by graphic health warnings on tobacco packaging at best-practice level
In the past 2 years, eight additional covering at least 50% of the pack, and countries, with 9% of the world’s More countries have need only add one criterion to achieve population, have joined the 93 countries adopted strong graphic best practice – eight of these need only that require large graphic warning health warnings than any mandate that the warnings appear labels on tobacco products. Two are on each package and any outside high-income countries (United States other MPOWER measure packaging used in the retail sale, and and Qatar), three are middle-income one country needs only to stipulate Twenty-three countries, representing countries (Mauritania, Montenegro rotation of warnings. 658 million people, are only one step and Nigeria), and three are low-income away from best-practice graphic Seven countries (Iraq, Israel, Japan, countries (Ethiopia, Gambia and Niger). health warnings. Maldives, Niue, Uganda, Uzbekistan), All eight countries strengthened existing with 255 million people, improved their laws to meet best-practice level. Eight countries, with a total of 435 legislation since 2018 but did not reach million people, need only increase the Of all MPOWER measures, large graphic best-practice level in 2020. size of the graphic health warnings pack warnings on cigarettes have to cover up to another 20% of the Of the 524 million people (6.7% of the seen the most progress since 2007 packages to meet all best-practice world’s population) who live in one of both in terms of countries acting and criteria for large graphic warnings. the world’s 100 largest cities, only 379 population covered by a best-practice An additional six countries, with a million (in 67 cities) are informed about policy. Since 2007, when only nine total population of 20 million, need the dangers of tobacco use by the display countries (5% of the world’s population) only add a requirement for a graphic of large graphic warning labels on their had large graphic pack warnings on image (instead of text only) to meet cigarette packs. One of these cities is cigarettes, an additional 92 countries best-practice. Nine other countries, covered by city-level legislation (Hong (with 55% of the world’s population) with a total population of 203 million, Kong SAR) and the remaining 66 are have acted to meet comprehensive have mandated large graphic warnings covered by national laws. graphic warning requirements.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 73 HEALTH WARNING LABELS (2020)
100% 6 Data not reported 90% 1 24 No warning or small warnings 80% 12 13 70% 17 Medium size warnings missing some or many appropriate 60% characteristics OR large warnings 12 50% missing many appropriate 5 characteristics 40% 42 Medium size warnings with all 30% 4 appropriate characteristics OR Proportion of countries 52
(Number of countries inside bars) large warnings missing some 20% appropriate characteristics 10% 7 Large warnings with all 0% appropriate characteristics High-income Middle-income Low-income
PROGRESS IN HEALTH WARNING LABELS (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5 101
93 4 77 100
4.7
3 Number of countries 4.0 Population protected (billions) Population 43 3.6 2 50 29 18 1.5 1 14 9 1.1 0.6 0.8 0.4 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
An increasing number of countries require plain packaging of tobacco products
Several countries are moving forward with plain packaging. By the end of 2020, 17 countries had adopted legislation mandating plain packaging of tobacco products and had issued regulations with implementation dates:
■ Australia ■ France ■ Israel ■ Norway ■ Slovenia ■ United Kingdom ■ Belgium ■ Hungary ■ Netherlands ■ Saudi Arabia ■ Thailand ■ Uruguay ■ Canada ■ Ireland ■ New Zealand ■ Singapore ■ Turkey
74 | WORLD HEALTH ORGANIZATION Mauritania goes from no health warnings to large graphic health warnings packaging requirements
Mauritania has been Party to Since then the Minister of Health large pictorial warnings required, the WHO FCTC since 2005, and has issued a decree in February of with all appropriate characteristics in June 2018 introduced its first 2020, regulating the warnings. This and more. The country is now one of tobacco control legislation – the came into force on May 30, 2021. the 14 highest achieving countries of culmination of a long-running effort The decree prohibits the inclusion the African Region in 2020 in terms that included the involvement of of descriptive terms or other signs of health warning labels (joined dedicated parliamentarians, civil that directly or indirectly give the recently by Ethiopia and Gambia), society (including the Centre for impression that a particular tobacco and has already banned smoking in Tobacco Control in Africa), and the product is less harmful than others, public places and on public transport. WHO Country Office. including terms such as “low tar”, “light”, A 2018 law concerning the “ultralight” or “soft”, Production, Importation, Distribution, etc, or other terms that Sale, Advertising, Promotion and have a similar meaning Consumption of Tobacco and its in other languages. The Products, stated that packages or requirements apply to packs cartridges, and all forms of outer and any external packaging, packaging of tobacco products, must including cartons. include a health warning covering at least 70% of the surface on both Mauritania is one of the sides. These warnings must include rare examples of a country pictures and text, and be written that has gone from no in Mauritania’s official languages. warning requirements to Graphic health warning label, Mauritania
Graphic health warnings mark the biggest change in labelling in four decades in the United States
Cigarette smoking remains the of the front and rear of tobacco States as the 22nd country in the leading cause of preventable packages and at least 20% of the Region of the Americas to attain disease, disability, and death in the top of cigarette advertisements. The the highest achievement for “W” United States,1 and authorities have warnings include a broad selection as per the MPOWER measures. therefore taken steps to strengthen of text as well as graphic images. measures to warn the public of the This move is considered the most risks associated with tobacco use. significant change in cigarette After several attempts to issue labelling in the United States and implement regulations that since 1984. It reflects successive align with the Family Smoking governments’ commitment to Prevention and Tobacco Control Act protect the population from the 2009 (attempts that were met by harms caused by tobacco and to legal challenges from the tobacco close the gaps in public awareness industry), a new rule issued by the about the adverse effects of One of 13 proposed warning label featuring FDA in March 2020 has mandated tobacco. It is anticipated that the text statements accompanied by photo- 11 new warnings on various health proposed rule will take effect in July realistic colour images depicting lesser known health risks of cigarette smoking (228). conditions to occupy the top 50% 2022,1 and will place the United
1 US Food and Drug Administration. See https://www.fda.gov/regulatory-information/search-fda-guidance-documents/required-warnings-cigarette-packages-and- advertisements-small-entity-compliance-guide-revised for more information.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 75 ANTI-TOBACCO MASS MEDIA CAMPAIGNS
Article 12 of the WHO FCTC states:
“Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools, as appropriate. … each Party shall … promote … broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristics of tobacco consumption and exposure to tobacco smoke; … [Each party shall promote] public awareness about the risks of tobacco consumption and exposure to tobacco smoke, and about the benefits of the cessation of tobacco use and tobacco-free lifestyles; … [each party shall promote] public awareness of and access to information regarding the adverse health, economic, and environmental consequences of tobacco production and consumption”. WHO FCTC Article 12 guidelines are intended to assist Parties in meeting their obligations under Article 12 of the WHO FCTC (174).
reduce second-hand smoke exposure use behaviour, but campaigns with a Hard-hitting mass media (230–235). As such it is imperative that duration of as little as 3 weeks can also campaigns are effective these campaigns form an important part have a positive impact (231, 237–239). of all comprehensive tobacco control and essential While expensive, mass media strategy or programmes (236). campaigns can quickly and efficiently Mass media anti-tobacco campaigns are Television campaigns using graphic reach large populations (234) with commonly used in high-income countries imagery are especially effective in messages and information on how but have been shown to be effective in motivating quit attempts (234, 236). to quit, and can include toll-free quit low- and middle-income countries as Sustained campaigns involving multiple line numbers on campaign products, well (229). There is strong evidence that communication channels (i.e. TV, radio e.g. at the bottom of posters or at if well-designed and hard-hitting, they and the Internet) are more likely to the end of TV advertisements. can reduce tobacco use, increase quit have a longer-term impact on tobacco attempts, lower youth initiation rates and Anti-tobacco mass media campaigns
ANTI-TOBACCO MASS MEDIA CAMPAIGNS – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries with the highest level of achievement: *Angola, Belarus, *Cabo Verde, *China, Costa Rica, *Cuba, El Salvador, Estonia, *Ethiopia, France, Georgia, The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO Germany,the part of WHO *Ghana, concerning *Guyana, the legal status Indonesia, of any country, Ireland, territory, *Japan,city or area *Kazakhstan, or of its authorities, *Latvia, or concerning *Malaysia, the delimitation *Monaco, of its *Morocco,Map Production: Myanmar, WHO GIS Centre *Namibia, New Zealand, Norway, frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI *Palau, Qatar, Republic of Korea, *Russian Federation, *Rwanda, Saint Lucia, *Saudi Arabia, *Thailand, Timor-Leste, Togo, Tonga, *Tunisia, Turkey,© WHO Turkmenistan, 2021. All rights reserved. *Tuvalu, *Ukraine, United Kingdom, United States of America, Viet Nam. * Country newly at the highest level since 31 December 2018.
76 | WORLD HEALTH ORGANIZATION Mass media campaigns have been neglected for too long – more than half of countries ran no recent national campaign.
countries (26% of middle-income monitored was 2009-10. Since then, More than half of the countries); and three were low-income the total number of people exposed to world’s population countries (10% of low-income a best-practice mass media campaign were not exposed to a countries). More than half of the rose until 2013-14, when 4.3 billion countries in the world (103) have not people lived in countries airing such best-practice mass media run any kind of sustained campaign in campaigns. Regrettably, this number campaign in 2020 the past 2 years, leaving about 17% of dropped to 1.8 billion people in 2018. the world’s population unreached by In 2020, the campaign implemented in Almost half of the world’s population any national campaign. China brings the total population back (3.3 billion people) live in a country up to 3.3 billion. that has aired at least one national anti-tobacco mass media campaign at Most countries that run campaigns best-practice level in the past 2 years. National mass media do not repeat the effort every 2 years. Another 39% of the population lived efforts continue to lag Since 2009-10, only three countries in countries that conducted mass have run a best-practice campaign media campaigns of at least 3 weeks’ People in low-income countries are every 2 years (Turkey, United Kingdom duration, with some but not all the least exposed to anti-tobacco mass and Viet Nam). Seven countries ran a best-practice criteria. media: over 64% of the population best-practice campaign five times over of low-income countries, living in 21 the six 2-year periods, missing only Of the 45 countries that ran a countries, have not been exposed one opportunity to sustain the series best-practice anti-tobacco campaign to any kind of national campaign in of campaigns (Australia, El Salvador, during that time, 15 were high-income the past 2 years. The first period for Ireland, Malaysia, Norway, Republic countries (25% of high-income which mass media campaigns were of Korea and United States). countries); 27 were middle-income
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 77 MASS MEDIA CAMPAIGNS (2020)
1 Data not reported 90% No national campaign conducted 80% 29 between July 2018 and June 53 2020 with a duration of at east 70% three weeks 60% 21 National campaign implemented 50% 2 with 1-4 appropriate characteristics 10 40% National campaign implemented 15 with 5-8 appropriate characteristics, 30% 14 Proportion of countries 1 or with 7 characteristics excluding (Number of countries inside bars) 20% airing on TV and/or radio 4 10% 15 27 National campaign implemented 3 with at least 7 appropriate 0% characteristics including airing High-income Middle-income Low-income on TV and/or radio
PROGRESS IN ANTI-TOBACCO MASS MEDIA CAMPAIGNS (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 4.3 100 4.1
3.4
3 3.3 Number of countries
Population protected (billions) Population 2.5 2 42 1.8 45 50 35 37 39 39 1
0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
78 | WORLD HEALTH ORGANIZATION Bringing “smoke-free” home: a mass media campaign in Thailand
Tobacco use is responsible for over 70 000 deaths campaign titled “Stop destroying your child’s dream” annually in Thailand, and tobacco-related illness were to promote social awareness of the dangers is the country’s leading cause of death (including of second-hand smoke in homes and to encourage approximately 9000 from second-hand smoke (200). smokers to quit for the benefits of the family, especially While the Non-Smokers’ Health Protection Act B.E. young children. The campaign is currently being 2535 (1992) made all public places non-smoking evaluated for reach and impact. areas, it was recognized that homes are the places Since 2010, when mass media data was first that families, and especially children, spend most of collected for this report, Thailand has consistently run their time, and where they are likely to be exposed to anti-tobacco mass media campaigns with at least six of second-hand smoke. Notably, a survey by Thailand’s the eight criteria used to assess level of achievement. National Statistical Office in 2017 found that as many as 17.3 million people across the country were exposed to second-hand smoke in their homes.
In 2019, partners from across sectors worked together to develop a mass media campaign to prevent young children from exposure to second-hand smoke at home, which was the theme of the established Action on Smoking and Health (ASH Thailand) “Smokefree Home” project. The campaign was strategically developed collaboratively by partners from across sectors employing the findings of focus group discussions with the target audience, and media such as television, radio, print, outdoor billboards, online advertising, and transit advertising to maximize the impact of the campaign. The main objectives of the The “Stop destroying your child’s dream” anti-tobacco campaign, Thailand
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 79 ENFORCE BANS ON TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Article 13 of the WHO FCTC states:
“... [A] comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products. Each Party shall ... undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship. … [W]ithin the period of 5 years after entry into force of this Convention for that Party, each Party shall undertake appropriate legislative, executive, administrative and/or other measures and report accordingly in conformity with Article 21”(41). WHO FCTC Article 13 guidelines are intended to assist Parties in meeting their obligations under Article 13 of the WHO-FCTC (174).
Promotional and sponsorship activities TAPS bans help protect can also influence businesses that may TAPS bans must be the population against the benefit from the billions of dollars comprehensive and tobacco industry invested in TAPS themselves. well-enforced And, wherever possible, the tobacco Despite tobacco companies’ insistence industry attempts to avoid regulation TAPS bans must be comprehensive that the billions of dollars they spend by adopting weak voluntary advertising because partial bans have little or no annually on advertising is only to codes, discrediting the evidence base for effect (231, 247, 250). When bans increase their market share at the restrictions, and using both lobbyists and are not comprehensive, tobacco expense of competitors, there is litigation to avoid TAPS bans (231, 246). companies exploit legal loopholes or indisputable evidence that TAPS simply shift their investments to forms activities also increase or sustain of promotion that are not banned tobacco use by both the effective (247, 251, 252). Bans must therefore recruitment of new tobacco users or TAPS bans reduce cover all TAPS activities, including by discouraging tobacco users from tobacco use direct promotion (e.g. TV advertising, quitting (231, 240, 241). radio, print publications and billboards TAPS bans are effective in reducing as well as advertising at points of Tobacco companies use a mix of tobacco sales and tobacco consumption sale); and indirect promotion (e.g. marketing techniques tailored to in all parts of the world (246–249) brand stretching and brand sharing, different groups and target specific and their impact may be even more free distribution, price discounts, populations through new products that dramatic in low- and middle-income product placement on TV/films and circumvent regulations and maintain countries than in high-income countries sponsorships including “corporate social acceptability (242). Youth and (249). Comprehensive bans on all TAPS social responsibility” programmes) women are especially targeted in activities are a key tobacco control (253). Bans must also include point of low- and middle-income countries (234). strategy and policy measure (174, 247) sale product displays that “normalize” Tobacco advertising and promotion and are one of only two WHO FCTC the products, prompt people to increases the likelihood that adolescents provisions with a mandatory timeframe smoke, encourage impulse purchases, will start to use tobacco which may lead for implementation (the other one is interfere with quitting, and increase the to a higher prevalence of adult tobacco Article 11 of the Convention). susceptibility of children and youth to users in the future (241, 244, 245). see and try the products (254–259).
80 | WORLD HEALTH ORGANIZATION Enforce bans on tobacco advertising ENFORCE BANS ON TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries with the highest level of achievement: Afghanistan, Albania, Algeria, Antigua and Barbuda, Azerbaijan, Bahrain, Benin, Brazil, Chad, Colombia, Congo, *Côte d’Ivoire, Democratic Republic of the Congo, Djibouti, Eritrea, *Ethiopia, Finland, Gambia, Ghana, Guinea, Guyana, Iceland, Iran (Islamic Republic of), *Iraq, *Jordan, Kenya, Kiribati, Kuwait, Libya, Madagascar, Maldives, Mauritania, Mauritius, Mongolia, Nepal, Niger, Nigeria, Niue, Panama, Qatar, Republic of
Moldova,The designations Russian employed Federation, and the presentation Saudi of theArabia, material Senegal, in this publication Seychelles, do not imply Slovenia, the expression Spain, of any Suriname, opinion whatsoever Togo, on Turkey,Data Tuvalu, Source: WHOUganda, United Arab Emirates, Uruguay, Vanuatu, the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre *Venezuelafrontiers or boundaries. (Bolivarian Dotted and Republic dashed lines of), on maps Yemen. represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI © WHO 2021. All rights reserved. * Country newly at the highest level since 31 December 2018.
Bans must also encompass the financial or in-kind contributions that tobacco TAPS bans should apply The number of countries companies may make to another entity to digital media covered by TAPS bans for deserving or socially responsible continues to steadily rise causes. These contributions fall within The growth in communications the definition of tobacco sponsorship technology and the use of Internet-based Although TAPS bans remain an in article 1(g) of the WHO FCTC and mobile phones means TAPS activities under-adopted measure, 57 countries should therefore be banned (253). can appear via multiple social media (21% of the world’s population) have Corporate social responsibility activities platforms – and children and adolescents comprehensive bans on TAPS. In 2007 are typically employed to convince are particularly exposed (260), not there were only eight countries – 4% governments to delay and refrain least through social media influencers, of the world’s population – with best- from implementing tobacco control spokespeople, and brand-sponsored practice TAPS bans in place. Since then, programmes and should also be contests that are used to promote an additional 49 countries (including included in TAPS bans (259). tobacco products (261, 262). Countries’ five since 2018 – Côte d’Ivoire, Ethiopia, existing legislation banning TAPS may not Legislation should use clear, Iraq, Jordan, and Venezuela (Bolivarian necessarily clearly or explicitly include a uncomplicated language and Republic of)) have introduced TAPS ban on advertisements on the Internet, unambiguous definitions, and avoid bans effectively, increasing global so ensuring that bans are inclusive of providing lists of prohibited activities population coverage to 1.6 billion. Internet-based media is crucial (263, that are, or could be understood 264). In some cases, enforcing TAPS to be, exhaustive (249). Moreover, bans on social media sites may require legislation must be coupled with strong cross-border legislation, and for this enforcement and monitoring, with high reason, countries will need to cooperate financial penalties for violations (174). and coordinate efforts (262).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 81 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP (2020)
100% Data not reported 90% 11 19 Complete absence of ban, or ban 10 80% that does not cover national TV, radio and print media 70% Ban on national TV, radio and 60% 55 print media only 50% 36 7 Ban on national TV, radio and 40% print media as well as on some but not all other forms of direct 30% and/or indirect advertising Proportion of countries
(Number of countries inside bars) 20% 12 Ban on all forms of direct and/or 31 indirect advertising (or at least 14 10% 90% of the population covered 0% by complete subnational bans) High-income Middle-income Low-income
PROGRESS IN BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 100
4.7
3 Number of countries 4.0 57 52 Population protected (billions) Population 3.6 2 41 50 32 25 1 19 12 1.6 8 1.2 1.4 0.7 0.9 0.3 0 0.2 0.2 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
82 | WORLD HEALTH ORGANIZATION Montenegro, Netherlands, South More than a third of An additional 2.1 billion Africa). Five countries and territories low-income countries people could easily be need only to ban industry sponsorship have complete TAPS bans covered by TAPS bans (Egypt, Sudan, Syrian Arab Republic, United Kingdom, Viet Nam). Three In 2020, of the 57 countries with A best-practice TAPS ban has 10 need only ban promotional discounts comprehensive TAPS bans, 12 are appropriate characteristics. In 2020, (Cyprus, Lebanon, Papua New Guinea). low-income countries (40%), 31 26 countries covering 2.1 billion Norway need only ban brand-sharing, are middle-income countries (30%) people had mandated nine of these Tonga need only ban the appearance of and 14 are high-income (23%). In 10 characteristics and thus were only tobacco products or brands in TV and/ a further 10 low-income countries one provision away from achieving or films, and one territory - occupied TAPS bans are either minimal (do not a best-practice TAPS ban. The most Palestinian territory, including east include advertising on national TV, common missing provision is banning Jerusalem - need only ban the free radio and print media) or completely advertising at point of sale (eight distribution of tobacco products. absent. The same is true in 19 middle- countries), followed by banning brand Over a quarter of the 524 million income countries and 11 high-income stretching (seven countries). Forty people who live in 29 of the world’s countries. Seven countries (Armenia, countries, with 1.2 billion people, 100 largest cities are protected by a Belgium, Bolivia (Plurinational State of), have a complete absence of TAPS TAPS ban. All of these cities are covered Denmark, Israel, Pakistan and Samoa) bans, or very minimal restrictions. by national laws. Instead of waiting – with a total 262 million people – Seven countries need only to ban for a national law to be put in place, improved their laws since 2018 but did brand-stretching (Croatia, France, the remaining 71 of the world’s largest not reach best practice in 2020. Georgia, Lithuania, Sri Lanka, Thailand, cities not currently protected by a Turkmenistan). Eight need only to ban national best-practice law could move advertising of tobacco products at point ahead with city, state or provincial of sale (Argentina, Bolivia (Plurinational level legislation to protect their large State of), Cook Islands, India, Mali, populations sooner.
The Bolivarian Republic of Venezuela institutes complete ban on tobacco advertising, promotion, and sponsorship
In 2019 The Bolivarian Republic Although some restrictions on TAPS Republic of Venezuela involved its of Venezuela achieved full existed before this regulation was promotion of cultural activities. implementation of its third passed, they did not cover points The Bolivarian Republic of MPOWER measure with the of sale. This was a particularly Venezuela’s TAPS ban now joins adoption of a Ministry of problematic gap, as the country’s the country’s two other measures Health Resolution completely Global Youth Tobacco Survey at the highest level – large pictorial banning tobacco advertising, in 2019 revealed that 44.3% health warnings on packages, promotion, and sponsorship, of students noticed tobacco and smoke-free regulation. The including the display of tobacco advertisements or promotions Bolivarian Republic of Venezuela’s products at points of sale. The when visiting points of sale (265). work to implement the WHO regulation also explicitly bans Establishing the ban required FCTC highlights the importance social corporate responsibility close coordination between the of Ministry of Health leadership, by tobacco industry actors. ministries of health and culture, as and shows that adopting measures one of the strategies used by the need not be a costly exercise. tobacco industry in The Bolivarian
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 83 Almost a third of middle and low-income countries are covered by comprehensive TAPS bans.
Effective collaboration between WHO and key government partners results in a comprehensive TAPS ban in Iraq
Bulldozer takes down a billboard advertising a cigarette brand
Following the release of the WHO bans on tobacco advertising, TAPS. With commitment from report on the global tobacco promotion and sponsorship (TAPS) senior leaders, Iraq demonstrated epidemic 2019, the Tobacco Free was recognized as a priority. The particular success. WHO worked Initiative in the WHO Eastern WHO team developed needed with the legal and executive Mediterranean Region worked resources to support countries in departments of the Iraqi Ministry with country-level stakeholders this area, including formulating of Health to support coordinated to identify key gaps in policy a draft ministerial decree that efforts for policy change through implementation and how to could be adapted across countries’ a ministerial decree. Ultimately, a support policy progress. various legal contexts. decision banning all forms of TAPS was introduced by the Minister Twelve Eastern Mediterranean Country teams in ministries of for Health and Environment in Region countries had not adopted a health and in WHO Country Offices Iraq, taking the country to the comprehensive ban in line with the used these technical resources to highest level of achievement WHO FCTC and thus strengthening advocate for stronger rules to ban of this MPOWER measure.
84 | WORLD HEALTH ORGANIZATION Enforcing TAPS bans through local action: Brazil, Indonesia and the Republic of Korea
Comprehensive bans on tobacco Meanwhile in Seoul, Republic drives. They also developed a advertising, promotion and of Korea, a plan has been simple, phone-based application sponsorship (TAPS) are effective developed to support stronger to support enforcement of the in reducing tobacco sales and enforcement of TAPS regulations outdoor ban. The city aims to consumption. However, TAPS bans across the city using the National achieve 90% compliance with both must be well enforced in order to Health Promotion Act’s Article indoor and existing outdoor bans deliver these benefits. 9-4 (Prohibition of, or Restriction on tobacco advertising. on, Advertisements of Tobacco). Through the Partnership for The city’s approach has included Healthy Cities, three cities have a key informant survey (adapted shown how local policies and for city-level use from a national activities can strengthen TAPS model provided by WHO) to enforcement. In Rio de Janeiro, assess public knowledge of, and Brazil, the city has enhanced the approaches to, compliance. implementation of a national TAPS ban by monitoring compliance. City Finally, local authorities in Jakarta, authorities have assessed points Indonesia, have strengthened of sale and provided training for enforcement of a local TAPS policy inspection agents, and have also banning outdoor advertisements Inspectors training for TAPS enforcement in run a communications campaign to by building capacity among Rio de Janeiro raise awareness about the ban and local government officials and its restrictions. conducting regular enforcement
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 85 RAISE TAXES ON TOBACCO
Article 6 of the WHO FCTC states: “...[P]rice and tax measures are an effective and important means of reducing tobacco consumption... [Parties should adopt]...measures which may include:...tax policies and...price policies on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption” (174).
Raising taxes to increase the Increased taxes can fund Tobacco tax policies need price of tobacco products expanded government strong tax administration is the single most effective health programmes Tax administration can be made easier if tobacco control measure Tax increases not only reduce tobacco the right tax policies are applied. Of the different types of tax levied on tobacco Increased taxes are highly cost-effective use and improve health, they also products, excise taxes are the most in reducing tobacco use (22, 198). In generate more government revenues effective at raising prices and triggering fact, a recent report published by the (22, 198). The report of the Task Force significant health impact (22, 274). Task Force on Fiscal Policy for Health on Fiscal Policy for Health also estimated Simpler tax structures are likewise easier estimated that tax increases that would that a 50% tobacco price increase in to administer – complex structures and lead to a 50% tobacco price increase 2017 would raise an additional US$ 3 tiered excise taxes should be avoided worldwide could avert 27.2 million trillion (US$ 2016 discounted) worldwide to diminish incentives for companies premature deaths over the next 50 over the next 50 years (266). Additional to price tobacco products in ways that years (266). Tobacco taxation is also funding generated by increased can undermine the health and revenue inexpensive to implement, costing taxation at country level could be used impact of tobacco taxes (22). low- and middle-income countries as for tobacco control programmes as little as US$ 0.05 per capita each year well as other important health and Strengthening tax and customs to administer (267). social initiatives, which have now been administration, as well as improving successfully demonstrated in some enforcement capacity, enhances On average, a 10% price increase will countries (271, 272). Using tax revenues the impact of raised tobacco taxes reduce consumption by 5% in low- in this way will further increase public (22). Key interventions to improve and middle-income countries (up to support for higher taxes. tax administration include ensuring 8% in some instances), and by about compliance (through licensing, detailed 4% in high-income countries (198). tax declaration requirements and Approximately half of this reduction advanced information technology), is due to tobacco users quitting, with Taxes should be raised ensuring control and enforcement on the other half the result of existing significantly and periodically the supply chain (through, for example, users smoking less (268). Tobacco the use of risk-based approaches for taxation is rightly considered as a highly Governments must monitor tobacco enforcement targets, tax stamps, cost-effective “best-buy” intervention, tax rates and prices relative to real track and trace systems, implementing meaning that the returns and economic income and significantly raise tax rates anti-forestalling methods), and benefits of this measure are several at regular intervals to ensure that using clearly defined procedures to times higher than its cost (269, 270). tobacco products do not become more affordable – a trend common in many follow after detecting illicit trade of countries where income and purchasing tobacco (including high penalties) power are growing rapidly (22). Despite (22). Experiences from numerous some of these countries raising tobacco countries show that illicit trade of tax rates, they have not offset inflation tobacco products can be successfully and income growth, causing an erosion addressed even when taxes and prices of the tax’s value and effectiveness are increased, hence the threat of tax in reducing consumption (22, 273). evasion should not be used as a reason Nominal tax increases that do not to forgo tax increases (22, 275). make tobacco products less affordable are unlikely to reduce consumption or encourage cessation.
86 | WORLD HEALTH ORGANIZATION Raise taxes on tobacco
RAISE TAXES ON TOBACCO – HIGHEST ACHIEVING COUNTRIES, 2020
Best-practice countries Other countries Not applicable
Countries and areas with the highest level of achievement: Andorra, Argentina, Belgium, Bosnia and Herzegovina, Brazil, Bulgaria, Chile, Croatia, Czechia, The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO *Denmark,the part of WHO Egypt, concerning Estonia, the legal statusFinland, of any France,country, territory, *Georgia, city or areaGreece, or of its Ireland, authorities, Israel, or concerning Italy, the Jordan, delimitation Latvia, of its Madagascar,Map Production: Malta, WHO Mauritius, GIS Centre Montenegro, *Morocco, frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI *Netherlands, New Zealand, North Macedonia, occupied Palestinian territory, Poland, *Portugal, Serbia, Slovakia, Slovenia, Spain, *Sri Lanka, Thailand,© WHO 2021. All rights reserved. Turkey, United Kingdom. * Country newly at the highest level since 31 December 2018.
countries lost their position in this top Gaining political buy-in is key One billion people are group (Australia, Austria, Colombia to adopting key tax reforms covered by high tobacco and Niue). The most significant tax taxes share increase seen in these six new The concerns around the political best-practice countries was made by economy of tobacco taxation are The evidence on tobacco interventions Sri Lanka, whose 2018 rate of 66.17% effectively exploited by the tobacco indicates that the most effective and was raised to 77.02% by 2020. No industry to block any major tobacco efficient way to reduce tobacco use is low-income countries have raised taxes tax reforms. Pre-emptively addressing to raise the price of tobacco through to 75% or above since 2018. Sixteen those concerns can greatly help the tobacco taxes. However, tobacco tax is countries, including eight low-income smooth adoption of important tobacco the least-adopted MPOWER measure. countries, increased taxes enough since tax reforms. Those concerns can be In 2020 only 13% of the world’s 2018 to move one category closer to summarized in the SCARE tactics (22): population living in 40 countries were best-practice level. S Smuggling and illicit trade protected by tax rates at 75% or more In 2008, 23 countries in the world had of the price of the most popular brand C Court and legal challenges tax rates at 75% or more of the price, of cigarettes. covering only half a million people or A Anti-poor rhetoric or regressivity The total number of countries that 7% of the world’s population. Since R Revenue reduction raised tobacco taxes to a level at or then, an additional half a billion people above 75% of the price of the most in 17 additional countries are covered E Employment impact sold brand of cigarettes increased by best-practice taxation levels. While from 38 in 2018 to 40 in 2020, but the 21 countries raised taxes sufficiently to Experience from countries around the number of people protected by this reach the highest group, four others world shows that these arguments level of tax remained at 1 billion. The dropped out of the group since 2008. are either unfounded or greatly addition of two countries to the total Today, middle-income countries exaggerated and that tax increases number of countries at the highest level constitute more than half of the are in fact good for health, for equity, of achievement represents a net gain population (61%) protected by the for revenues and for the economy after six countries (Denmark, Georgia, raised-taxes measure. Less than 3% of overall, with very little risk of facing Morocco, Netherlands, Portugal and protected people live in low-income legal threats, especially when laws are Sri Lanka) increased their taxes to countries. carefully designed and enacted (22). best-practice levels, while another four
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 87 TOTAL TAX ON CIGARETTES (2020)
100% 4 5 4 90% 2 4 16 80% 5 70% Data not reported 35 60% 25 < 25% of retail price 10 50% is tax
40% ≥ 25% and < 50% of retail 30% 35 price is tax Proportion of countries
(Number of countries inside bars) 20% 24 ≥ 50% and < 75% of retail 9 price is tax 10% 15 ≥ 75% of retail price is tax 0% 1 High-income Middle-income Low-income
PROGRESS IN TOTAL TAX ON CIGARETTES ≥ 75% OF RETAIL PRICE (2007–2020)
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5
4 100
3 Number of countries Population protected (billions) Population 2 50 38 40 31 33 32 23 28 1 1.0 1.0 0.5 0.6 0.6 0.6 0.6 0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
In 2020, 24 (40%) high income are just five percentage points or less Furthermore, 4% of high-income countries and 15 (15%) of middle- away from the best practice level, countries, 16% of middle-income income countries levied taxes at having tax rates between 70% and countries and 20% of low-income best-practice level. Only one low- 75% of retail price. If these countries countries do not tax tobacco even at income country – Madagascar – had increased their tax rates to 75%, an a minimal level (i.e. under 25% of the taxes at the highest level. However, additional 465 million people would retail price is tax). All 23 countries are 15 countries (10 high-income, four be covered by the most effective missing the opportunity to save lives middle-income and one low-income) measure to reduce tobacco use. by raising taxes to this basic level.
88 | WORLD HEALTH ORGANIZATION One in five countries are now protected by high tobacco taxes.
Low- and middle-income countries have much progress to make to raise taxes and prices
Price and tax levels are highest in average total tax as a proportion of fairly similar throughout the world. high-income countries, even when price amounting to 51.2% in There is a strong case for all countries, adjusting for differences in purchasing low-income countries and 59.1% particularly low- and middle-income power. Cigarette pack prices, total taxes in middle-income countries. This countries, to increase their excise taxes and the tobacco excise component as proportion reaches 67.4% in high- further, which will have the effect of a share of pack prices are all lower in income countries, even though the making cigarettes less affordable. low- and middle-income countries, with non-tax portion of cigarette prices is
WEIGHTED AVERAGE RETAIL PRICE AND TAXATION (EXCISE AND TOTALS) OF MOST SOLD BRAND OF CIGARETTES, 2020
8.94 Price minus taxes Other taxes Excise tax per pack 2.91 Price
5.62
1.23 4.88
2.15 1.99 Total taxes 2.48 = PPP $6.04 0.92 4.80 (67.6% of pack price) 0.85
Prices and taxation per pack (PPP dollars) Total taxes Total taxes 1.21 = PPP $3.49 = PPP $2.88 2.55 (61.5% of pack price) 2.03 (58.7% of pack price) 0.43 Total taxes = PPP $1.21 0.84 (50.1% of pack price)
High-income Middle-income Low-income Global
Note: Averages are weighted by WHO estimates of number of current cigarette smokers ages 15+ in each country in 2019. Prices are expressed in Purchasing Power Parity (PPP) adjusted dollars or international dollars to account for differences in the purchasing power across countries. Based on 54 high-income, 99 middle-income and 23 low-income countries with data on prices of most sold brand, excise and other taxes, and PPP conversion factors.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 89 for this current report. Using this Of the 524 million people (6.7% of the Affordability should be measure, cigarettes have become less world’s population) who live in one continuously monitored affordable in 84 countries and did not of the world’s 100 largest cities, only and decreased significantly change in 68 countries, 130 million (in 24 cities) are protected while they became more affordable in by tobacco taxation. No city has yet, To measure whether cigarettes have 20 countries. Of those 20 countries, 17 independently of national government, become more or less affordable over were low- and middle-income countries. introduced taxes on tobacco products that have resulted in raising the share time in a given country, price data from Affordability can change rapidly and of total taxes to 75% or more of the previous editions of this report were monitoring these changes can give retail price. used to compute the per capita GDP governments an indicator of when required to purchase 2000 cigarettes to best apply higher tobacco taxes. of the most sold brand reported in Automatic adjustments in taxes can each year. The average change over the be applied, which can account for period 2010–2020 was then calculated fluctuations in national economies.
CHANGE IN AFFORDABILITY OF CIGARETTES, 2010-2020
100% 6 8 90% 14 3 9 80%
70% 17 42 3 60% Could not be assessed due to 50% insufficient data 40% 9 Cigarettes became more affordable 30% Proportion of countries 34
(Number of countries inside bars) Affordability did not change 20% 42 10% 8 Cigarettes became less affordable 0% High-income Middle-income Low-income
Cigarettes have become less affordable since 2010 in 84 countries globally, equally distributed between high-income and low- and middle-income countries.
90 | WORLD HEALTH ORGANIZATION Raising taxes is key to comprehensive tobacco control, Morocco
After its manufactured tobacco specific tax, along with a minimum increases, total tax now represents sector was liberalized in 2011, tax collection amount for tobacco 76.1% of the price of the most Morocco embarked on a 3-year products. A minimum tax burden sold brand of cigarettes, reaching journey to reform its tobacco was also instated, where collected the highest level of achievement taxation structure. Inspired by how taxes could not represent less of the “R” component of the other countries had implemented than 53.6% of the retail price MPOWER package. The tax reforms tobacco control measures, this of cigarettes. and increases in rates resulted in reform aimed mainly at protecting increases in revenues which went And in 2017, as part of efforts to public health and consolidating up from 10.4 billion Moroccan further simplify Morocco’s tobacco state revenue. Dirham in 2013 to 12.8 billion tax structure, the consumption Moroccan Dirham in 2018. Morocco’s previous excise tobacco (excise) tax rate on dark tobacco tax system had comprised an cigarettes was applied to gradually And 2021 saw another increase ad valorem tax with a fixed reach (over a period of 3 years) a in the consumption tax on cigars, minimum price on all new brands uniform tax rate across all types cigarillos and water-pipe tobacco. introduced to the market – a of cigarettes, moving away from The country aims to continue system that incentivized companies the two-tiered system previously raising tobacco taxes on a regular to introduce low-cost brands in place. basis to compensate for inflation. and encouraged consumers to These gradual tax increases are Morocco further increased its buy cheap tobacco products. expected to increase prices and minimum excise tax on cigarettes reduce demand for tobacco, To address this, in 2013 Morocco in 2019, as well as its minimum thus decreasing their harmful introduced, in addition to the tax burden, which rose from consumption and burden of disease. existing ad valorem system, a 53.6% to 58%. Thanks to these
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 91 Georgia’s comprehensive tax policy reduces tobacco consumption
Tobacco tax rates in Georgia rose 10% in 2016 and further increased Georgian Lari (an increase of significantly between 2013 and to 30% of the retail price in 2019. 71%) reduced raw tobacco 2019. After separate rises in the consumption by 260% in 2020. To avoid substitution to other specific excise tax on filter cigarettes tobacco products, tax increases The evolution of Georgia’s total and on non-filter cigarettes, by 2018 were also applied to roll-your own tobacco tax burden, which consists both rates were equalized, leading (RYO) tobacco. In 2013, the excise of excise, ad-valorem and VAT, can to a uniform tax on all types of tax on 1 kg of imported raw tobacco be seen in the graph 1 below. By cigarettes. The excise tax on one was 20 Georgian Lari, and by 2018 2021 the tax burden represented pack of filtered cigarettes increased it had risen to 35 Georgian Lari. In 71% of the price of the most sold from 0.6 Georgian Lari perREAL pack PRICE of AND TAX BURDEN, PACK OF MOST SOLD BRAND 2019, the excise tax on raw tobacco brand – up from just 15% in 2012. 20 sticks (in 2013) to 1.7 GeorgianOF CIGARETTES, GEORGIA 2012–2021 (2012 BASE) had almost doubled to 60 Georgian The price also increased by 2.75 Lari6.0 (in 2017). For unfiltered Lari per kilogram. 86% times between 2012 and 2021.100% cigarettes, the specific excise was 72% 76% 74% 71% increased from 0.15 Georgian Lari By 2019, demand for unfiltered As shown in graph 2 below, there80% 60% per4.0 pack of 20 sticks (2013) to 1.7 cigarettes58% decreased by 96% is a clear downward trend in total 48% 60% Georgian Lari (2017). In43% 2015, all compared to the previous year. tobacco use thanks to sustained cigarettes were subject to a new For RYO, 2019 also seems increases in tobacco taxation and40% 2.0 15% additional ad valorem tax of 5% on to be a turning point – the the increase in tax across products, the retail price – a figure that rose to excise tax hike from 35 to 60 reducing risks for substitution.20% 0 0% 2012 2013 2014 2015 2016Graph 1: 2017 2018 2019 2020 2021 Retail priceREAL (real, PRICE 2012 ANDbase) TAX BURDEN, PACKTotal tax OF burden MOST SOLD BRAND OF CIGARETTES, GEORGIA 2012–2021 (2012 BASE) 6.0 86% 100% 72% 76% 74% 71% 80% 60% 4.0 58% 48% 60% 43% 40% 2.0 15% 20%
0 0% 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Retail price (real, 2012 base) Total tax burden
Graph 2: TOTAL MARKET OF LOCALLY PRODUCED FILTERED AND UNFILTERED CIGARETTES, AND RYO TOBACCO 2015–2020
511.61 490.34 495.02 450.53 387.62 344.99 Million packs
2015 TOTAL2016 MARKET OF LOCALLY2017 PRODUCED2018 FILTERED AND2019 2020 UNFILTERED CIGARETTES, AND RYO TOBACCO 2015–2020
511.61 92 | WORLD HEALTH ORGANIZATION 490.34 495.02 450.53 387.62 344.99 Million packs
2015 2016 2017 2018 2019 2020 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 93 NATIONAL TOBACCO CONTROL PROGRAMMES:
The WHO Framework Convention on Tobacco Control strongly suggests that countries set up a national tobacco control programme (NTCP) to lead their tobacco control efforts. To this end, WHO FCTC Article 5 states that: “Each Party shall develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes … [and] establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control.” In addition, WHO FCTC Article 26.2 sets out that: “Each Party shall provide financial support in respect of its national activities intended to achieve the objective of the Convention” (174).
that can be sustained over time (171) working on tobacco control objectives Every country should have and enable policies and programmes with fewer staff (80 countries), or a national tobacco control to reach as wide a population as with an unknown number of staff (33 programme to lead tobacco possible (277). On this note, NTCPs countries). Only 18 countries (with 152 should ensure that population million people) do not have a national control efforts subgroups with disproportionately agency for tobacco control, 13 of which high rates of tobacco use are are low- and middle-income countries. The WHO FCTC strongly suggests reached by policies and programmes that countries set up a national, In the past 2 years, four countries tailored to their needs (277). decentralized tobacco control enhanced their national tobacco control programme (NTCP) to lead their programmes sufficiently to reach the tobacco control efforts. Adequately highest level of adoption (Ghana, financed, clearly focused NTCPs or Tobacco control requires Hungary, Spain and Trinidad and coordination mechanisms are critical an actively involved Tobago), adding 89 million people to for developing and maintaining the the population covered. At the same sustainable policies that can reverse civil society time, two countries dropped below the tobacco epidemic (108). Ministries NTCPs require the involvement best-practice level: Cuba reduced the of health, or equivalent government of appropriate nongovernmental number of staff dedicated full-time to agencies, should take the lead on organizations and other civil society tobacco control, and Switzerland did strategic tobacco control planning and groups to maintain progress on national not report the number of staff. policy setting, with other ministries or as well as global tobacco control efforts Over the more than a decade since agencies reporting to this centralized (108). NTCPs must specifically exclude 2008, substantial progress has authority (251). Tobacco control the tobacco industry and its allies, which been achieved with a total of 18 programmes should also be integrated cannot be legitimate stakeholders in countries, home to 598 million people, into countries’ broad health and tobacco control efforts (171). establishing a well-staffed national development agendas (276). Almost a third of countries globally team working full time on tobacco In large countries or those with federal (60 countries) have a national agency control. It is worth noting that this political systems, decentralizing NTCP with responsibility for tobacco control measure may underestimate the true authority to subnational level can allow objectives staffed by at least five extent of NTCPs in countries because more flexibility in policy development full-time equivalent people, meaning information on tobacco control and programme implementation. that 66% of the world’s population programme staffing at the national Public health and government leaders are served by such an agency. An level is incomplete, and there is no at appropriate subnational levels additional 113 countries (with another formal mechanism for collecting this must be given adequate resources one third of the world’s population) are information from countries. to build implementation capacity
94 | WORLD HEALTH ORGANIZATION Almost a third of countries globally have a national agency with responsibility for tobacco control objectives staffed by at least five full-time equivalent people.
NATIONAL TOBACCO CONTROL PROGRAMMES (2020)
100% 2 Data not reported 3 12 2 90% 3 80% No national agency for tobacco control 70% Existence of national agency with 60% 40 59 14 responsibilty for tobacco control 50% objectives with less than 5 staff or staff not reported 40% 30% Proportion of countries Existence of national agency (Number of countries inside bars) 20% with responsibilty for tobacco 10 16 34 control objectives and at least 10% 5 staff members 0% High-income Middle-income Low-income
PROGRESS IN NTCP (2008–2020) AT HIGHEST LEVEL OF ACHIEVEMENT
8 200
Total population: 7.8 billion Total number of countries: 195 7
6 150
5 5.1 5.0 5.0 5.0 4.8 4.9 4 4.5 100
3 Number of countries 58 60 55
Population protected (billions) Population 52 44 49 2 42 50
1
0 0 2007 2008 2010 2012 2014 2016 2018 2020
Population (billions) Countries
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 95 National Tobacco Control Programme, India
Strong, nationally funded The Indian government has The three-tiered NTCP framework tobacco control programmes are strategically invested in scaling (consisting of national, state and the cornerstone of WHO FCTC up tobacco cessation through district tobacco control cells) enables implementation. India established mCessation services and the toll-free the government to take strong, one of the world’s largest public- National Tobacco Quitline, which has evidence-based policy measures such funded NTCPs in 2007 – within 2 four hubs servicing different regions as banning ENDS, implementing years of the WHO FCTC coming of the country. The Quitline is staffed large pack warnings, a tobacco- into force. India’s vast NTCP is by 100 trained counsellors providing free films policy, and tobacco-free now implemented in all 700 of the services in over 15 languages to educational institution guidelines. country’s districts. address the needs of 267 million These policies and initiatives have adult tobacco users in India. Key pillars of the programme reduced the prevalence of adult (funded and staffed at national, And to support tobacco product tobacco use by 17% (relative state, and district level) include: (a) regulation, the government has reduction) between 2009 and training and capacity building for established three tobacco testing 2016 – proof that that adequate stakeholders, including law enforcers; laboratories – the first of their commitment and public investment (b) education and communication kind in the WHO South East Asia in comprehensive tobacco control activities; (c) school programmes; (d) Region. To track key tobacco policies results in substantial public monitoring tobacco control laws; and control indicators, robust tobacco health gains, even in high prevalence, (e) provision of cessation support, surveillance (in the form of regular tobacco-producing countries. including pharmacological treatment. GATS and GYTS surveys) have been Activities and interventions are dovetailed with the programme, adapted and designed according to with subnational level estimates. local needs.
Awareness generation among school/college going youth on the harmful effects of tobacco use through street play (nukkad natak) in Uttar Pradesh, India
96 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 97 ELECTRONIC NICOTINE DELIVERY SYSTEMS
As discussed in the background chapter on ENDS, MPOWER measures as well as age restrictions on sales and flavour bans can be applied to ENDS. Here we assess the status of these measures as they are applied to ENDS globally.
Almost half of countries monitor Forty-four of the countries that monitor E-cigarette use among adolescent e-cigarette use adolescents’ e-cigarette use are adults should be routinely Most surveys that ask about ENDS middle-income countries, while 42 incorporated into nationally use focus on e-cigarette use and not are high-income countries. Only one representative surveys low-income country (Yemen) currently on broader ENDS use. Eighty-seven Currently, 56 countries representing conducts surveys on adolescents that countries monitor e-cigarette use among a population of 4.9 billion people incorporate questions about current adolescents through national school- capture e-cigarette use among adults e-cigarette use. based surveys. This means that 45% of in nationally representative surveys countries with 3.5 billion people have that – of which are low-income data on e-cigarettes use among children countries. Meanwhile, a total of 139 and adolescents that can be used to countries, representing a population guide local policy decisions. Not all of 2.8 billion people (of which 4.1 survey a consistent age group however, billion live in 113 low- and middle- making global comparisons challenging. income countries) have no data on adult current e-cigarette use at all.
Monitoring e-cigarette use among adolescents MONITORING E-CIGARETTE USE AMONG ADOLESCENTS USING NATIONAL SCHOOL-BASED SURVEYS COMPLETED IN 2020 OR EARLIER
E-cigarette use among adolescents is monitored by national school-based surveys
E-cigarette use among adolescents is not monitored by national school-based surveys
Not applicable
Countries that monitor ENDS use among adolescents: Albania, Antigua and Barbuda, Argentina, Australia, Austria, Belize, Bolivia (Plurinational State of), Brazil, The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO Bruneithe part ofDarussalam, WHO concerning Bulgaria,the legal status Canada, of any country, China, territory, Colombia, city or area Croatia, or of its authorities, Cuba, Cyprus, or concerning Czechia, the delimitation Denmark, of its DominicanMap Production: Republic, WHO GIS Ecuador, Centre El Salvador, Estonia, Fiji, Finland, frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI France, Germany, Ghana, Greece, Grenada, Guatemala, Guyana, Hungary, Iceland, Iraq, Ireland, Italy, Jamaica, Japan, Kazakhstan, Kiribati, Kyrgyzstan,© WHO 2021. Lao All rights reserved. People’s Democratic Republic, Latvia, Lithuania, Luxembourg, Malaysia, Malta, Marshall Islands, Mauritius, Monaco, Mongolia, Montenegro, Netherlands, New Zealand, Nicaragua, Niue, North Macedonia, Norway, Panama, Papua New Guinea, Paraguay, Peru, Poland, Portugal, Qatar, Republic of Korea, Romania, Russian Federation, Saint Lucia, Saint Vincent and the Grenadines, San Marino, Serbia, Slovakia, Slovenia, Spain, Suriname, Sweden, Switzerland, Thailand, Trinidad and Tobago, Ukraine, Unites States of America, Uruguay, Vanuatu, Venezuela, Viet Nam, Yemen.
98 | WORLD HEALTH ORGANIZATION Monitoring e-cigarette use among adults MONITORING E-CIGARETTE USE AMONG ADULTS USING NATIONAL SCHOOL- BASED SURVEYS COMPLETED IN 2020 OR EARLIER
E-cigarette use among adults is monitored by national population-based surveys
E-cigarette use among adults is not monitored by national population-based surveys
Not applicable
Countries that monitor ENDS use among adults: Argentina, Australia, Austria, Bolivia (Plurinational State of), Brunei Darussalam, Bulgaria, Canada, Chile China, Colombia,The designations Costa employed Rica, and theCyprus, presentation Czechia, of the materialDenmark, in this Ecuador,publication do Estonia, not imply theFinland, expression France, of any opinion Germany, whatsoever Greece, on Hungary,Data Source: Iceland, WHO Indonesia, Ireland, Italy, Kazakhstan, the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre Latvia,frontiers orLithuania, boundaries. Dotted Luxembourg, and dashed lines Malaysia, on maps represent Malta, approximate Marshall border Islands, lines for Mexico, which there Nepal, may not Netherlands, yet be full agreement. New Zealand,for Health, Panama, DNA/DDI Philippines, Poland, Qatar, Republic of Korea, Romania, Russian Federation, Senegal, Serbia, Slovenia, Spain, Sweden, Switzerland, Ukraine, United Arab Emirates, Unites States of America, Uruguay,© WHO Viet2021. All Nam. rights reserved.
ENDS should not be left unregulated.
Too many countries do not Measures that ban ENDS use 110 countries either have no graphic regulate ENDS in public indoor places, apply tobacco health warning measures in Globally, 111 countries have adopted health warnings on ENDS place (24 countries), or where they do measures addressing ENDS. Thirty-two and ban on ENDS advertising, exist, ENDS are not explicitly covered of these countries ban the sale of ENDS. promotion and sponsorship by them (86 countries). Thirty-two Seventy-nine countries (over 40% of all should all be applied countries ban the sale of ENDS and therefore do not mandate health countries), allow the sale of ENDS but Excluding countries that ban sale of warnings for them. have adopted one or more measures ENDS, 30 countries completely ban either fully or partially to regulate them. the use of ENDS in all public places, Twenty-two countries completely ban These measures include bans on the workplaces and public transport; an advertising, promotion and sponsorship use of ENDS in public indoor areas; additional 45 countries partially ban their of ENDS devices, e-liquids or both (15 bans on advertising, promotion and use in these places. The remaining 120 ban these activities for both devices and sponsorship; and the application of countries have either no smoke-free place e-liquids; four ban them only for ENDS graphic health warnings on packaging measures (37 countries), or ENDS are devices; and three ban them only for as well as age restrictions on the sale of not explicitly covered by such measures e-liquids). An additional 53 countries ENDS and flavoring bans or restrictions. where they exist (83 countries). have partial advertising, promotion The remaining 84 countries, home to and sponsorship measures in place Only eight countries mandate the use of 27% of the world’s population, have no that cover ENDS. The remaining 120 large graphic health warnings on ENDS regulations in place addressing ENDS. countries either have no such measures packaging meeting full criteria, two of in place (16 countries), or where they While 84% of high-income countries which apply these requirements only do exist, ENDS are not explicitly covered have either a regulation or a sales to ENDS devices and not to e-liquids. by them (104 countries). ban in effect, half of middle-income Another 45 countries mandate some countries and three-quarters of form of health warning on either low-income countries have taken no ENDS devices, e-liquids or both. And regulatory action concerning ENDS.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 99 HIGH-INCOME COUNTRIES MIDDLE-INCOME COUNTRIES LOW-INCOME COUNTRIES
Measures include: 1. Prohibiting the use of ENDS in public indoor areas 2. Graphic health warnings applied to packaging 3. Prohibiting the advertisement, promotion and sponsorship of ENDS 4. Minimum age restrictions applied to sale of ENDS 5. Ban on flavours
Sale is banned Full or partial measures No measures
100 | WORLD HEALTH ORGANIZATION Measures applied to ENDS
MEASURES APPLIED TO ENDS, 2020
Full or partial measure adopted Sale is banned No measure or ban No data Not applicable
Note: 13 countries have both a sales ban and additional ENDS regulation in place, and these are classified here as sales-ban countries. Please see Annex II Table 2.1 The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO forthe partfurther of WHO details. concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. for Health, DNA/DDI © WHO 2021. All rights reserved. ENDS are regulated in the following countries: Albania, Algeria, Andorra, Armenia, Australia, Austria, Azerbaijan, Barbados, Belarus, Belgium, Bulgaria, Cameroon, Canada, Chile, China, Congo, Costa Rica, Cote d’Ivoire, Croatia, Cyprus, Czechia, Denmark, Ecuador, El Salvador, Estonia, Fiji, Finland, France, Georgia, Germany, Greece, Guyana, Honduras, Hungary, Iceland, Ireland, Israel, Italy, Jamaica, Kazakhstan, Kenya, Lao People’s Democratic Republic, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Nepal, Netherlands, New Zealand, Niue, Norway, Palau, Papua New Guinea, Paraguay, Philippines, Poland, Portugal, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Saint Lucia, San Marino, Saudi Arabia, Serbia, Slovakia, Slovenia, Spain, Sweden, Tajikistan, Togo, Turkey, Tuvalu, Ukraine, United Arab Emirates, United Kingdom, United States of America, Uzbekistan.
Sale of ENDS is banned in the following countries and territories: Argentina, Bahrain, Brazil, Brunei Darussalam, Cambodia, Democratic People’s Republic of Korea, Egypt, Ethiopia, Gambia, India, Iran (Islamic Republic of), Iraq, Jordan, Kuwait, Lebanon, Malaysia, Mauritius, Mexico, occupied Palestinian territory, Oman, Panama, Qatar, Singapore, Sri Lanka, Suriname, Syrian Arab Republic, Thailand, Timor-Leste, Turkmenistan, Uganda, Uruguay, Venezuela (Bolivarian Republic of).
SELECTED LEGISLATIVE MEASURES APPLIED TO ENDS, 2020
100% 16 No measures for tobacco or ENDS 24 90% 37 Criteria* fully or partially met for tobacco but no measures for ENDS 80% Criteria* partially met for ENDS 70% 104 Criteria* fully met for ENDS 60% 83 86 * for a list of the criteria, refer to Technical Note I 50%
40% # 32 countries with a ban on sale of ENDS are excluded from this indicator 30% 1 In 2 countries this measure applies to ENDS 45 523 devices only, and in 9 countries this measure 20% 451 applies to e-liquids only 2 In 2 countries this measure applies to ENDS 10% devices only, not e-liquids 4 30 22 3 82 In 2 countries this measure applies to ENDS 0% devices only, and in 1 country this measure Use in public places, Health Advertising, promotion applies to e-liquids only # workplaces and warnings and sponsorship 4 In 4 countries this measure applies to ENDS public transport devices only, and in 3 countries this measure applies to e-liquids only
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 101
COUNTRIES APPLYING MINIMUM AGE OF SALES RESTRICTIONS ON ENDS VERSUS TOBACCO, 2020
100%
80%
60%
40%
20%
0% ENDS Tobacco SELECTED LEGISLATIVE MEASURES APPLIED TO ENDS, 2020
100% 16 No measures for tobacco or ENDS Finland’s ban on flavours and24 aromas in e-cigarettes liquids 90% 37 Criteria* fully or partially met for tobacco but no measures for ENDS 80% In 2016, Finland introduced pioneering e-cigarette regulations that banned use of flavourings, set minimum-age Criteria* partially met for ENDS 70%limits for buyers, provided import restrictions, banned the use of e-cigarettes in non-smoking areas and prohibited e-cigarette marketing, display and distance-selling. Following these104 revisions to Finland’s TobaccoCriteria* Act, fully liquids met used for ENDS in 60% 83 e-cigarettes are available exclusively in tobacco86 flavour in Finland. Through a combination* for of a swift list of theaction criteria, and refer stringent to Technical Note I 50%regulation, Finland achieved further declines in smoking prevalence (from 15% in 2016 to 14% in 2018) without seeing a contingent rise in daily e-cigarette use (less than 1% in 2018). The country has set an ambitious goal of bringing both 40% # 32 countries with a ban on sale of ENDS are tobacco and nicotine products below a prevalence rate of 5% within the next decade. excluded from this indicator 30% 1 In 2 countries this measure applies to ENDS 45 523 devices only, and in 9 countries this measure 20% 451 applies to e-liquids only 2 In 2 countries this measure applies to ENDS 10% devices only, not e-liquids 4 30 22 3 82 In 2 countries this measure applies to ENDS 0% devices only, and in 1 country this measure Use in public places, Health Advertising, promotion applies to e-liquids only Flavours should be banned There# is no consistency in countries (55%) impose no excise tax workplaces and warnings and sponsorship 4 In 4 countries this measure applies to ENDS on open systems e-liquids. And of the to reduce thepublic appeal transport of taxing ENDS devices only, and in 3 countries this measure 44 countries where data are available ENDS products to children As they are often priced and taxed applies to e-liquids only for closed systems, 57% (25 countries) and adolescents differently, data was collected for impose no excise tax on closed systems Excluding countries that ban the sale of e-liquids used in both open and closed e-liquids (commonly sold as pods). ENDS, only 3 countries have adopted systems. Open systems are devices a ban all flavours in ENDS, except for that allow the user to buy e-liquids In countries where an excise tax is “tobacco” flavour (Finland, Hungary and fill their device with the mixtures imposed on ENDS e-liquids, the tax is and Montenegro). Six other countries they want (with no nicotine, different generally low, with only three countries ban only selected flavours or permit nicotine concentrations and/or levying taxes equal to, or above, 75% specific flavours (Denmark, Estonia, flavours). Closed systems are products of the price of the cheapest brand Germany, New Zealand, Philippines, that come with a prefilled container for open systems e-liquids (Portugal, Saudi Arabia). (called a cartridge, pod or tank) and Russian Federation and Slovenia). For where own mixes are not possible. closed systems e-liquids, no country applies taxes as high as 75% of the Age restrictions on the sale Of the 51 countries where data are price of the cheapest brand of closed of ENDS has been adopted available for open-systems ENDS, 28 by only 69 countries system ENDS. Of the 163 countries that permit the sale of ENDS, 69 countries limit their COUNTRIES APPLYING MINIMUM AGE OF SALES RESTRICTIONS sale to a minimum age (18 years in ON ENDS VERSUS TOBACCO, 2020 62 countries, 19 years in one country and 21 years in six countries), while 100% the other 94 countries do not. This means 42% of countries restrict access 80% to ENDS by age compared to 90% of countries which apply these restrictions 60% to tobacco. 40%
20%
0% ENDS Tobacco
102 | WORLD HEALTH ORGANIZATION ENDS closed-system e-liquids tax policy
ENDS CLOSED SYSTEM E-LIQUIDS TAX POLICY, 2020
Excise on closed-system e-liquids No excise on closed-system e-liquids Sale is banned No data Not applicable
CountriesThe designations with employed a tax and on the closed presentation system of the e-liquids:material in this Armenia, publication doAustria, not imply Azerbaijan,the expression of Bahrain, any opinion whatsoeverBelarus, onBelgium,Data Bosnia Source: andWHO Herzegovina, Bulgaria, China, Croatia, the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre Czechia,frontiers or boundaries.Denmark Dotted Estonia, and dashed France, lines on Georgia, maps represent Germany, approximate Greece, border lines Hungary, for which there Iceland, may not Indonesia, yet be full agreement. Ireland, Israel,for Health,Italy, DNA/DDIKazakhstan, Kyrgyzstan, Lithuania, Luxembourg, Malta, Netherlands, Pakistan, Peru, Poland, Portugal, Republic of Korea, Republic of Moldova, Romania, Russian Federation, Serbia, Spain, Sweden,© WHO Tonga, 2021. All rights reserved. Ukraine, United Arab Emirates, United Kingdom, Uzbekistan. ENDS open-system e-liquids tax policy
ENDS OPEN SYSTEM E-LIQUIDS TAX POLICY, 2020
Excise on open-system e-liquids No excise on open-system e-liquids Sale is banned No data Not applicable
Note: Jordan also has both a ban on the sale of ENDS and an excise The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on Data Source: WHO the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its Map Production: WHO GIS Centre Countriesfrontiers or boundaries. with a Dottedtax on and open dashed systems lines on maps e-liquids: represent approximate Albania, border Armenia, lines for Austria,which there Azerbaijan,may not yet be full Belarus, agreement. Belgium,for Bosnia Health, DNA/DDI and Herzegovina, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Iceland, Indonesia, Ireland, Israel, Italy, Jordan, Kazakhstan, Kyrgyzstan, Lao© WHO People’s 2021. All rights reserved. Democratic Republic, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Morocco, Netherlands, North Macedonia, Peru, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Tonga, Ukraine, United Kingdom, Uzbekistan, Yemen.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 103 Countries should consider Tobacco control must anticipate Measures applied to ENNDS are including ENDS cessation in nicotine and tobacco products often not consistent with those their cessation strategies will evolve rapidly and plan for applied to ENDS Many ENDS users wanting to quit use their regulation Data collected on ENNDS indicate tools such as toll-free quit lines, text In recent years, there have been that although 14 countries regulate message programmes and specialized newer nicotine and tobacco products (or ban the sale of) ENNDS in the tobacco dependence treatments. Data introduced to several markets. These same way they regulate ENDS, others from the largest quit line operator in are rapidly evolving and may have have differing approaches for these the United States (serving 23 states implications for regulation. Therefore, products, including banning the and over 700 employers and health the availability, characteristics and use sale of one when allowing the sale plans) showed that among the 74 of these and other emerging products of the other. Twenty-nine countries 646 quit line participants enrolled should be closely monitored going ban the sale of ENNDS and only one between January 2017 and June 2020, forward and regulations should be country explicitly bans both ENNDS 14% were using e-cigarettes and 2% future-proofed as much as possible to and ENDS (Iraq). Apart from sale of them were exclusive e-cigarette cover these products. This report did bans, 35 countries regulate ENNDS users. Therefore, the country’s national not collect data on nicotine pouches or but in ways that are inconsistent with tobacco cessation services should other novel nicotine products. measures applied to ENDS. A total of consider providing support for ENDS 117 countries with 4 billion people users to quit (1). are not covered by any measures that specifically address ENNDS. See Annex II for further details.
Note on Heated Tobacco Products
The Eighth Conference of the Parties to the WHO FCTC recognized HTPs as tobacco products and noted that they should therefore be subject to the provisions of the WHO FCTC, and monitored and regulated like other tobacco products. Data collected for this report indicate that HTPs are banned (sales ban or another type of ban that restricts their availability) in 11 countries, (Brazil, Democratic People’s Republic of Korea, Ethiopia, India, Iran (Islamic Republic of), Mexico, Norway, Panama, Singapore, Syrian Arab Republic, Timor-Leste). In the remaining 184 countries, HTPs are either implicitly or explicitly regulated as tobacco products, or explicitly regulated in other categories. Further analysis will be made in the future to understand better how these products are addressed by countries.
104 | WORLD HEALTH ORGANIZATION Examples of country actions applied to ENDS
Ukraine imposes taxes on ENDS and HTPs
Ukraine has committed itself to implementation campaign titled “There is no safe smoking” with the of the WHO FCTC COP-8 decision on regulating support of global health organization Vital Strategies. novel and emerging nicotine and tobacco products Social videos and public service announcements with a similar approach to that used for conventional (broadcast on television, on the Internet, on subway tobacco products. Thus, in 2019 the Ukraine parliament and train stations) were aimed at raising young people’s adopted Law Nº 466-IX that imposes taxes on the awareness of the health risks of using electronic liquids used in ENDS, ENNDS and HTPs starting from smoking devices. Residents of Kyiv, the capital of January 1, 2021. Ukraine, also saw social advertising on the city streets. The campaign reached around 25 million people and At the same time Ukraine worked to increase public evaluations showed that 73% of people received new knowledge about ENDS. From November 2020 to information via the campaign, and that 47% of ENDS January 2021, an NGO called Life, together with the and HTP users were motivated to quit as a result of it. Public Health Center, conducted a national information
Ukraine MPs, doctors, experts and activists unite to defend equal taxation rates for all tobacco products
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 105 Sri Lanka bans ENDS
Sri Lanka was one of the first countries in the South-East Asia Region to ban electronic cigarettes. As per “Prohibited Tobacco Products” regulations of 2016, no person in the country shall manufacture, import, sell or offer for sale any electronic cigarette that contains tobacco. This initiative shows the commitment of the country to effectively address the ongoing tobacco epidemic as electronic cigarettes could put people, specially youth, at risk of nicotine addiction.
Pictorial health warnings mandated on ENDS, Republic of Korea
In the Republic of Korea, ENDS have been regulated as Since December 2016, three rounds of health warnings tobacco products under the Tobacco Business Act since have been issued by the Ministry of Health and Welfare, January 2014. Although the ENDS industry strongly and images for the warnings on ENDS have changed opposed displaying health warnings on ENDS products, every 2 years to deliver the message more effectively pictorial health warnings on all nicotine and tobacco on the harm of ENDS use. The Republic of Korea was products have become mandatory. the first country in the world to make pictorial health warnings obligatory on ENDS, and its experience The Tobacco Pictorial Health Warning Committee, of doing so provides a valuable example of how to composed of representatives from the Ministry of consultatively develop and implement health warnings Health and Welfare, the Ministry of Finance, the on emerging and novel nicotine and tobacco products Ministry of Gender Equality and Family, academia based on scientific evidence. and experts from public health, youth education, communication, and civil society organizations, reviewed the most recent available scientific evidence on tobacco products to draw up a list of topics for the warnings. In addition, the Ministry of Health and Welfare conducted focus group interviews and online public surveys to identify the most powerful text and images for health warnings, and evaluated existing health warnings from around the world.
23 December 2016 to 23 December 2018 to 23 December 2020 to 22 December 2018 22 December 2020 22 December 2022
Changes in the pictorial health warning on e-cigarettes in Republic of Korea
106 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 107 CONCLUSION
In the 13 years during which MPOWER has come about through the collective appropriate”, measured by the reduction has been monitored, there have been and coordinated efforts of a global of tobacco use in adults. Tobacco use tremendous strides made in tobacco community dedicated to tobacco reduction is also one of the 16 trace control. At the same time there have control. But there is still so much work indicators to measure (and is a major been countless challenges – perhaps the ahead of us. Only two countries in contributor to) the Healthier Billion greatest of which was faced in 2020 in the world (Brazil and Turkey) have put component of the WHO Triple Billion the shape of the COVID-19 pandemic. all MPOWER measures in place at a Targets, an initiative to help countries comprehensive level. And although the deliver on the SDGs. Despite these hurdles, there are now 5.3 prevalence of smoking has declined billion people who are protected by at The focus of this report, addressing across most of the world, as the total least one best-practice tobacco control new and emerging products, charts population grows, the total number of measure – 4.2 billion more than were a new threat to tobacco control. people smoking remains high. covered in 2007. Conversely, 2.4 billion ENDS are increasingly available in people remain unprotected by evidence- Every country has an obligation to many countries along with other based tobacco control best practices, protect the health of its people, and all novel products like heated tobacco leaving them at risk from the health and Parties to the WHO FCTC have made products and nicotine pouches. As economic harms caused by tobacco. a commitment to implement strong they emerge and rapidly evolve, these tobacco control policies as an important products can be difficult to characterize There has been inspiring progress in means of fulfilling their obligation to and therefore bring with them many tobacco control since the adoption of protect the health of their people. regulatory challenges. At the same the WHO FCTC and the introduction The SDGs have also underscored the time, the tobacco and related industries of MPOWER. Billions of lives are now importance of this commitment and behind these newer products pedal better protected and millions of lives call to “strengthen the implementation misinformation campaigns, marketing have been saved over the years. This of the WHO FCTC in all countries, as them as “clean”, “smoke-free” or
108 | WORLD HEALTH ORGANIZATION “safer”, and claim they are effective bans or graphic health warnings for There has been inspiring progress in the cessation aids. By doing so, these ENDS; however, 39 of these are only 13 years since MPOWER monitoring industries attempt to appear part of partially adopted. This leaves a total 84 began, but still there are many challenges the solution to the tobacco epidemic, countries with no legislation addressing to overcome in order to achieve the as opposed to instigators and ENDS in any of these domains. commitments countries have made perpetrators of the epidemic. These through the WHO FCTC, the SDGs and The data also show that only a handful industries also target children and the Noncommunicable Diseases Global of countries ban flavours in ENDS, and adolescents by using marketing Action Plan to reduce tobacco use and a few more regulate them. In parallel to strategies and thousands of flavours bring a swift end the tobacco epidemic. this, 94 countries do not limit the sale of that make ENDS and other nicotine Countries should remain vigilant and ENDS to a minimum age, making these and tobacco products appealing. When maintain focus on implementing products freely available to minors. children use ENDS, or even try them, evidence-based measures that are they are more than twice as likely And where data are available on tax proven to reduce tobacco use, and avoid to use conventional cigarettes. The rates, these rates are generally low, distractions caused by the proliferation of tobacco industry gains new customers. with only three countries taxing ENDS newer products. As the world emerges e-liquids at 75% or more of the retail from the COVID-19 pandemic, the call The evidence from this report indicates price. Too many countries remain to build back better should be central to that 32 countries currently ban the vulnerable to the tactics used by the tobacco control. We must all recommit sale of ENDS, taking a strong stance tobacco and related industries to expand to strengthening implementation on preventing the potential harms their markets. Countries should protect of the WHO FCTC, strive to adopt they pose to their populations. A their populations, and in particular MPOWER measures at the highest level further 79 countries have adopted their children and adolescents, from of achievement, and ensure that all the bans on use in public indoor areas, unregulated novel and emerging people of the world are protected from advertising, promotion or sponsorship tobacco and nicotine products. the harms of tobacco and nicotine.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 109 REFERENCES
1. Political declaration of the third high-level 10. Conference of the Parties to the WHO 20. EcigIntellligence [website]. Regulatory meeting of the General Assembly on the Framework Convention on Tobacco Control. and market intelligence for the e-cigarette prevention and control of noncommunicable Decision FCTC/COP8/8(22) Novel and sector. London: Tamarind Media; 2021 diseases. WHO Secretariat Report to the emerging tobacco products. Geneva: World (https://ecigintelligence.com/about- WHO Executive Board. Geneva: World Health Health Organization; 2018 (https://www.who. ecigintelligence/,accessed 2 July 2021). Organization; 2021 (EB148/7; https://apps. int/fctc/cop/sessions/cop8/FCTC_COP8(22). who.int/gb/ebwha/pdf_files/EB148/B148_7- pdf?ua=1, accessed 13 August 2020). 21. E-cigarettes. In: Tobacco Tactics [website]. en.pdf at paras 24-28, accessed 1 July 2021). Bath, UK: University of Bath: 2021 (https:// 11. Conference of the Parties to the WHO tobaccotactics.org/wiki/e-cigarettes/, 2. Responding to noncommunicable diseases Framework Convention on Tobacco Control. accessed 2 July 2021, accessed 2 July 2021). during and beyond the COVID-19 pandemic. Decision FCTC/COP/7(11) endorsed in COP Geneva: World Health Organization; 2020 FCTC/COP7(9). Delhi, India: World Health 22. WHO technical manual on tobacco tax policy (https://www.who.int/publications/i/item/ Organization; 2016. and administration. Geneva: World Health WHO-2019-nCoV-Non-communicable_ Organization; 2021. diseases-Policy_brief-2020.1, accessed 12. Conference of the Parties to the WHO 1 June 2021). Framework Convention on Tobacco Control. 23. Addiction at any cost: Philip Morris Decision FCTC/COP8/8 endorsed in COP International uncovered. New York, USA: 3. UN Interagency Taskforce on NCDs, COVID-19 FCTC/COP8(21). Geneva: World Health Stopping Tobacco Organizations and Products and NCD risk factors [infographic]. Geneva: Organization; 2018. (STOP); 2018 (https://exposetobacco.org/ World Health Organization; 2020 (https:// wp-content/uploads/STOP_Report_Addiction- www.who.int/docs/default-source/ncds/ 13. Conference of the Parties to the WHO At-Any-Cost.pdf, accessed 1 July 2021). un-interagency-task-force-on-ncds/uniatf- Framework Convention on Tobacco policy-brief-ncds-and-covid-030920-poster. Control. Decision FCTC/COP7(14) Further 24. Wagener TL, Floyd EL, Stepanov I, Driskill LM, pdf?ua=1, accessed 1 July 2021). development of the partial guidelines for Frank SG, Meier E et al. Have combustible implementation of Articles 9 and 10 of the cigarettes met their match? The nicotine 4. Alqahtani JS, Oyelade T, Aldhahir AM, WHO FCTC (Regulation of the contents delivery profiles and harmful constituent Alghamdi SM, Almehmadi M, Alqahtani of tobacco products and Regulation of exposures of second-generation and third- AS et al. Prevalence, severity and mortality tobacco product disclosures). Geneva: World generation electronic cigarette users. Tobacco associated with COPD and smoking in Health Organization; 2016 (https://www. Control. 2017;26(e1): e23–e28. patients with COVID-19: a rapid systematic who.int/fctc/cop/cop7/FCTC_COP7(14)_ review and meta-analysis. PLoS One. EN.pdf?ua=1, accessed 21 July 2021). 25. Traboulsi H, Cherian M, Abou Rjeili M, 2020;15(5):e0233147. Preteroti M, Bourbeau J, Smith BM et al. 14. Raymond BH, Collette-Merrill K, Harrison RG, Inhalation toxicology of vaping products 5. Sitas, F, Harris-Roxas B, Bradshaw D, Lopez Jarvis S, Rasmussen RJ. The nicotine content and implications for pulmonary health. AD. Smoking and epidemics of respiratory of a sample of E-cigarette liquid manufactured International Journal of Molecular Science. infections. Bulletin of the World Health in the United States. Journal of Addiction 2020;21(10). Organization. 2021;99(2):164–165. Medicine. 2018;12(2):127–131. 26. E-cigarette, or vaping, products visual 6. Del Sole F, Farcomeni A, Loffredo L, Carnevale 15. Tobore TO. On the potential harmful effects dictionary. Atlanta, GA: Centers for Disease R, Menichelli D, Vicario T et al. Features of of E-Cigarettes on the developing brain: Control [no date] (https://www.cdc.gov/ severe COVID-19: a systematic review and the relationship between vaping-induced tobacco/basic_information/e-cigarettes/ meta-analysis. European Journal of Clinical oxidative stress and adolescent/young adults pdfs/ecigarette-or-vaping-products-visual- Investigation. 2020;50(10):e13378. social maladjustment. Journal of Adolescence. dictionary-508.pdf, accessed 2 July 2021). 2019;76:202–209. 7. Secretariat of the WHO Framework 27. Kosmider L, Cox S, Zaciera M, Kurek J, Convention on Tobacco Control. Information 16. O’Brien D, Long J, Quigley J, Lee C, McCarthy Goniewicz ML, McRobbie H et al. Daily note on classification of novel and emerging A, Kavanagh P. Association between exposure to formaldehyde and acetaldehyde tobacco products. WHO Framework electronic cigarette use and tobacco cigarette and potential health risk associated with Convention on Tobacco Control. Geneva: smoking initiation in adolescents: a systematic use of high and low nicotine e-liquid World Health Organization; 2019. review and meta-analysis. BMC Public Health. concentrations. Scientific Reports. 2021;21(954):e1-e10. 2020;10(1):6546. 8. Conference of the Parties to the WHO Framework Convention on Tobacco Control. 17. Sæbø G, Scheffels J. Assessing notions of 28. Talih S, Salman R, El-Hage R, Karaoghlanian Decision FCTC/COP6(9) Electronic nicotine denormalization and renormalization of N, El-Hellani A, Saliba N et al. Effect of free- delivery systems and electronic non-nicotine smoking in light of e-cigarette regulation. base and protonated nicotine on nicotine yield delivery systems. Geneva: World Health International Journal of Drug Policy. from electronic cigarettes with varying power Organization; 2014 (https://apps.who.int/ 2017;49:58–64. and liquid vehicle. Scientific Reports 2020;10. gb/fctc/PDF/cop6/FCTC_COP6(9)-en.pdf, accessed 21 July 2021). 18. Petrescu D, Vasiljevic M, Pepper J, Ribisl K, 29. Jackler RK, Ramamurthi D. Nicotine arms race: Marteau T. What is the impact of e-cigarette JUUL and the high-nicotine product market. 9. Conference of the Parties to the WHO adverts on children’s perceptions of tobacco Tobacco Control. 2019;0:1–6. doi:10.1136/ Framework Convention on Tobacco Control. smoking? An experimental study. Tobacco tobaccocontrol-2018-054796. Decision FCTC/COP8(22) Novel and emerging control. 2017;26(4):421–427. tobacco products. Geneva: World Health 30. Zhu SH, Sun JY, Bonnevie E, Cummins SE, Organization; 2018 (https://www.who.int/ 19. Choi K, Grana R, Bernat D. Electronic nicotine Gamst A, Yin L et al. Four hundred and fctc/cop/sessions/cop8/FCTC_COP8(22). delivery systems and acceptability of adult sixty brands of e-cigarettes and counting: pdf?ua=1, accessed 13 August 2020). cigarette smoking among Florida youth: implications for product regulation. Tobacco renormalization of smoking? Journal of Control. 2014; 23:iii3–iii9 Adolescent Health. 2017;60(5):592–598.
110 | WORLD HEALTH ORGANIZATION 31. Hsu G, Sun JY, Shu-Hong Z. Evolution of 43. A systematic review of health effects of 55. Berry KM, Fetterman JL, Benjamin EJ, electronic cigarette brands from 2013–2014 electronic cigarettes. Geneva; World Health Bhatnagar A, Barrington-Trimis JL, Leventhal to 2016–2017: Analysis of brand websites. Organization: 2015. AM et al. Association of electronic cigarette Journal of Medical Internet Research. use with subsequent initiation of tobacco 2018;20(3):e80. 44. Skotsimara G, Antonopoulos AS, Oikonomou cigarettes in US youths. JAMA Open Network. E, Siasos G, Ioakeimidis N, Tsalamandris S 2019;2(2):e187794. 32. Barrington-Trimis J, Samet J McConnell R. et al. Cardiovascular effects of electronic Flavorings in electronic cigarettes. Journal cigarettes: a systematic review and meta- 56. Yuan M, Cross S, Loughlin S. Leslie F. of the American Medical Association. analysis. European Journal of Preventive Nicotine and the adolescent brain. Journal 2014;312(23):2493. Cardiology. 2019;26(11) :1219–1228. of Physiology. 2015;593(16):3397–3412.
33. Strombotne K, Buckell J, Sindelar JL. Do 45. Kennedy CD, van Schalkwyk MCI, McKee 57. Hall F, Der-Avakian A, Gould T, Markou A, JUUL and e-cigarette flavours change M, Pisinger C. The cardiovascular effects of Shoaib MJY. Negative affective states and risk perceptions of adolescents? Evidence electronic cigarettes: a systematic review of cognitive impairments in nicotine dependence. from a national survey. Tobacco Control. experimental studies. Preventive Medicine. Neuroscience & Biobehavioral Reviews. 2021;Mar;30(2):199–205. doi: 10.1136/ 2019;127:105770. 2015;58:168–185. tobaccocontrol-2019-055394. Epub 2020 Apr 16. 46. Tsai M, Byun MK, Shin J, Crotty Alexander LE. 58. Quick facts on the risks of e-cigarettes for Effects of e‐cigarettes and vaping devices on kids, teens, and young adults. In: Smoking 34. van de Nobelen S, Kienhuis AS, Talhout R. cardiac and pulmonary physiology. The Journal and Tobacco Use [website]. Atlanta, GA: An inventory of methods for the assessment of Physiology. 2020;598(22):5039–5062. Centers for Disease Control; 2020 (https:// of additive-increased addictiveness of tobacco www.cdc.gov/tobacco/basic_information/ products. Nicotine & Tobacco Research. 47. Gotts JE, Jordt S-E, McConnell R, Tarran e-cigarettes/Quick-Facts-on-the-Risks-of-E- 2016;18(7):1546–1555. R. What are the respiratory effects of cigarettes-for-Kids-Teens-and-Young-Adults. e-cigarettes? British Medical Journal. html, accessed 2 July 2021). 35. Preliminary scientific evaluation of the 2019;366. possible public health effects of menthol 59. Whittington J, Simmons P, Philips A, Gammill versus nonmenthol cigarettes. Silver Spring, 48. Wills TA, Soneji SS, Choi K, Jaspers I, Tam S, Cen R, Magann E et al. The use of Maryland: Food & Drug Administration; 2013. EK. E-cigarette use and respiratory disorders: electronic cigarettes in pregnancy: a review of an integrative review of converging evidence the literature. Obstetrical and Gynecological 36. Krüsemann EJ, Boesveldt S, De Graaf K, from epidemiological and laboratory studies. Survey. 2018;73(9):544–549. Talhout R. An e-liquid flavor wheel: a European Respiratory Journal. 2021;57(1): shared vocabulary based on systematically e1-e16. 60. Froggatt S, Reissland N, Covey J. The effects reviewing e-liquid flavor classifications in of prenatal cigarette and e-cigarette exposure literature. Nicotine and Tobacco Research. 49. Use of e-cigarettes (vapes) among adults on infant neurobehaviour: a comparison 2019;21(10):1310–1319. in Great Britain. London: Action on Smoking to a control group. EClinicalMedicine. and health; 2020. 2020;28:100602. 37. Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette use among middle 50. WHO study group on tobacco product 61. Behar R, Davis B, Wang Y, Bahl V, Lin S, Talbot and high school students – United States, regulation. Report on the scientific basis of P. Identification of toxicants in cinnamon- 2020. Morbidity and Mortality Weekly Report. tobacco product regulation: eighth report of flavored electronic cigarette refill fluids. 2020;69(37):1310. a WHO study group. Geneva: World Health Toxicology in Vitro. 2014;28(2):198–208. Organization; 2021. 38. Rose SW, Johnson AL, Glasser AM, Villanti 62. Krishnan-Sarin S, O’Malley SS, Green BG, AC, Ambrose BK, Conway K et al. Flavour 51. Wang JB, Olgin JE, Nah G, Vittinghoff Jordt S-E. The science of flavour in tobacco types used by youth and adult tobacco users E, Cataldo JK, Pletcher MJ et al. products. In: Report on the scientific basis in wave 2 of the Population Assessment of Cigarette and e-cigarette dual use and of tobacco product regulation: Seventh Tobacco and Health (PATH) Study 2014–2015. risk of cardiopulmonary symptoms in report of the WHO study group on tobacco Tobacco Control. 2020;29(4):432–446. the Health eHeart Study. PLoS One. product regulation. Geneva: World Health 2018;13(7):e0198681. Organization; 2019:125–142. 39. Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette use among middle 52. Kim C-Y, Paek Y-J, Seo HG, Cheong YS, Lee 63. Outbreak of lung injury associated with and high school students – United States, CM, Park SM et al. Dual use of electronic and the use of e-cigarette, or vaping, products. 2020. Morbidity and Mortality Weekly Report. conventional cigarettes is associated with In: Smoking and Tobacco Use [website]. 2020;69:1310–1312. higher cardiovascular risk factors in Korean Atlanta, GA: Centers for Disease Control; men. Scientific Reports. 2020;10(1):1–10. 2020 (https://www.cdc.gov/tobacco/basic_ 40. Population Assessment of Tobacco and information/e-cigarettes/severe-lung-disease. Health: Wave 4. US Food and Drug 53. Reddy KP, Schwamm E, Kalkhoran S, Noubary html, accessed 2 July 2021). Administration; Silver Spring, Maryland; F, Walensky RP Rigotti NA. Respiratory 2016–2017. symptom incidence among people using 64. Pray IW, Atti SK, Tomasallo C, Meiman JG. electronic cigarettes, combustible tobacco, E-cigarette, or vaping, product use-associated 41. ASHRAE Position document on environmental or both. American Journal of Respiratory and lung injury among clusters of patients tobacco smoke. Atlanta, Georgia: ASHRAE; Critical Care Medicine. 2021;Apr 15. doi: reporting shared product use – Wisconsin, 2016 (https://www.ashrae.org/File%20 10.1164/rccm.202012-4441LE. 2019. Morbidity and Mortality Weekly Report. Library/About/Position%20Documents/ 2020;69(9):236–240. pd_environmental-tobacco-smoke-2020-07-1. 54. National Center for Chronic Disease, P, Health pdf, accessed 2 July 2021). Promotion Office on S Health, Reports of the 65. Public health consequences of e-cigarettes. Surgeon General. In: The health consequences Washington, DC: National Academies Press 42. Stevens EM, Hébert ET, Tackett AP, Leavens of smokin–50 years of progress: a report of (US); 2018. ELS, Wagener TL. Harm perceptions the Surgeon General. Atlanta, GA; Centers for of the JUUL E-cigarette in a sample Disease Control and Prevention: 2014. 66. Seitz CM, Kabir Z. Burn injuries caused by of ever users. International Journal of e-cigarette explosions: a systematic review Environmental Research and Public Health. of published cases. Tobacco Prevention & 2020;17(13):4755 Cessation. 2018;4:32.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 111 67. Rossheim ME, Livingston MD, Soule EK, 79. Choi, B Abraham I. The decline in e-cigarette 92. Eissenberg T, Soule E, Shihadeh A. Zeraye HA, Thombs DL. Electronic cigarette use among youth in the United States: an “Open-System” electronic cigarettes cannot explosion and burn injuries, US Emergency encouraging trend but an ongoing public be regulated effectively. Tobacco Control. Departments 2015–2017. Tobacco Control. health challenge. Journal of the American 2021;30:234–235. 2019;28(4):472–474. Medical Association. 2021;4(6):e2112464. 93. Meernik C, Baker HM, Kowitt SD, Ranney 68. Govindarajan P, Spiller HA, Casavant MJ, 80. Perikleous EP, Steiropoulos P, Paraskakis LM, Goldstein AO. Impact of non-menthol Chounthirath T, Smith GA. E-cigarette and E, Constantinidis TC, Nena E. E-cigarette flavours in e-cigarettes on perceptions and liquid nicotine exposures among young use among adolescents: an overview of the use: an updated systematic review. BMJ Open. children. Pediatrics. 2018;141(5). literature and future perspectives. Frontiers in 2019;9(10):e031598. Public Health. 2018;6:86. 69. Fernández E, Ballbè M, Sureda X, Fu M, Saltó 94. De Andrade M, Hastings G, Angus K. E, Martínez-Sánchez JM. Particulate matter 81. Barrington-Trimis, JL, Kong G, Leventhal AM, Promotion of electronic cigarettes: tobacco from electronic cigarettes and conventional Liu F, Mayer M, Cruz TB et al. E-cigarette use marketing reinvented? British Medical Journal. cigarettes: a systematic review and and subsequent smoking frequency among 2013;347. observational study. Current Environmental adolescents. Pediatrics. 2018;142(6). Health Reports. 2015;2(4):423–429. 95. Barrington-Trimis JL, Urman R, Leventhal AM, 82. Yoong SL, Hall A, Leonard A, McCrabb S, Gauderman WJ, Cruz TB, Gilreath TD et al. 70. Li L, Lin Y, Xia T, Zhu Y. Effects of electronic Wiggers J, Tursdan d’Espaignet E, et al. E-cigarettes, cigarettes, and the prevalence cigarettes on indoor air quality and Association between electronic nicotine of adolescent tobacco use. Pediatrics. health. Annual Review of Public Health. delivery systems and electronic non-nicotine 2016;138(2). 2020;41(1):363–380. delivery systems with initiation of tobacco use in individuals aged <20 years - a 96. Goldenson NI, Leventhal AM, Stone 71. Hess I, Lachireddy K, Capon A. A systematic systematic review and meta-analysis. MD, McConnell RS, Barrington-Trimis JL. review of the health risks from passive PLOS One. [in press] Associations of electronic cigarette nicotine exposure to electronic cigarette vapour. Public concentration with subsequent cigarette Health Research & Practice. 2016;26(2). 83. Hartmann-Boyce, J, McRobbie H, Lindson smoking and vaping levels in adolescents. N, Bullen C, Begh R, Theodoulou A et al. JAMA Pediatrics. 2017;171(12): 1192–1199. 72. Guidelines for implementation of Article 8: Electronic cigarettes for smoking cessation. protection from exposure to tobacco smoke. Cochrane Database Syst Rev. 2020; 10: 97. Etter JF, Bullen C. Electronic cigarette: users World Health Organization Framework Cd010216. profile, utilization, satisfaction and perceived Convention on Tobacco Control. Geneva: efficacy. Addiction. 2011;106:2017–2028. World Health Organization; 2007. 84. Smoking cessation: a report of the Surgeon General. Washington, DC: US Department of 98. Neuberger M. The electronic cigarette: a wolf 73. Borgini A, Veronese C, De Marco C, Boffi R, Health and Human Services; 2020 (https:// in sheep’s clothing. Wien Klin Wochenschr. Tittarelli A, Bertoldi M et al. Particulate matter pubmed.ncbi.nlm.nih.gov/32255575/, 2015;127(9-10):385–7. in aerosols produced by two last generation accessed 17 July 2021). electronic cigarettes: a comparison in a 99. Stanwick R. E-cigarettes: Are we real-world environment. Pulmonology. 2021. 85. Scientific Committee on Health, Environmental renormalizing public smoking? Reversing five and Emerging Risks (SCHEER). Opinion on decades of tobacco control and revitalizing 74. Exposure to aerosols from smoking-proxy electronic cigarettes. Luxembourg: SCHEER; nicotine dependency in children and youth electronic inhaling systems: a systematic 2021. in Canada. Paediatric and Child Health. review. Barcelona: Tobacco Control Unit, 2015;20(2):101–5. Institut Català d’Oncologia; 2016. 86. Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical 100. Everard CD, Silveira ML, Kimmel HL, Marshall 75. Lerner CA, Sundar IK, Yao H, Gerloff J, settings: a systematic review and meta- D, Blanco C, Compton WM. Association of Ossip DJ, McIntosh S et al. Vapors produced analysis. Lancet Respiratory Medicine. electronic nicotine delivery system use with by electronic cigarettes and e-juices 2016;4(2):116–28. cigarette smoking relapse among former with flavorings induce toxicity, oxidative smokers in the United States. JAMA Open stress, and inflammatory response in lung 87. Sawant AM, Mali DP, Bhagwat DA. Regulatory Network. 2020;3(6):e204813. epithelial cells and in mouse lung. PLoS One. requirements and drug approval process 2015;10(2):e0116732. in India, Europe and US. Pharmaceutical 101. Manzoli L, Flacco ME, Ferrante M. Cohort Regulatory Affairs. 2018;7(2). study of electronic cigarette use: effectiveness 76. Tobacco questions for surveys. a subset of and safety at 24 months. Tobacco Control. key questions from the Global Adult Tobacco 88. Nicotine e-cigarettes laws are changing. 2017;26:284–92. Survey (GATS). 2nd edition. Geneva: World Canberra: Australian Government, Health Organization; 2011 (https://apps.who. Department of Health, Therapeutic Goods 102. Pokhrel P, Herzog TA, Muranaka N. Contexts int/iris/handle/10665/87331, accessed 2 July Administration; 2021 (https://www.tga.gov. of cigarette and e-cigarette use among dual 2021). au/blogs/tga-topics/nicotine-e-cigarettes- users: a qualitative study. BMC Public Health. laws-are-changing, accessed 17 July 2021). 2015;15:859. 77. Yoong SL, Hall A, Leonard A, McCrabb S, Wiggers J, Tursdan d’Espaignet E, et al. 89. Baker TB, Fiore MC. What we do not know 103. Global burden of 87 risk factors in 204 Prevalence of electronic nicotine delivery about e-cigarettes is a lot. JAMA Open countries and territories, 1990–2019: systems and electronic non-nicotine delivery Network. 2020;3(6):e204850. a systematic analysis for the Global systems in children and adolescents: a Burden of Disease Study 2019. Lancet. systematic review and meta-analysis. Lancet 90. Leventhal AM, Goldenson NI, Barrington- 2020;396(10258):1223–1249. Public Health. 2021. doi:10.1016/S2468- Trimis JL, Pang RD, Kirkpatrick MG. Effects 2667(21)00106-7. of non-tobacco flavors and nicotine on 104. Goniewicz ML, Hajek P, McRobbie H. e-cigarette product appeal among young Nicotine content of electronic cigarettes, its 78. Surgeon General’s Advisory on E-cigarette adult never, former, and current smokers. Drug release in vapour and its consistency across use among youth. Atlanta, GA; Centers for and Alcohol Dependence. 2019;203:99–106. batches: regulatory implications. Addiction. Disease Control; 2019 (https://www.cdc. 2014;109(3):500–7. gov/tobacco/basic_information/e-cigarettes/ 91. WHO global report on trends in prevalence surgeon-general-advisory/index.html, of tobacco use 2000-2025, third edition. 105. How to quit e-cigarettes. World Health accessed 17 July 2021). Geneva: World Health Organization; 2019. Organization. Geneva: World Health Organization; 2021.
112 | WORLD HEALTH ORGANIZATION 106. Electronic Nicotine Delivery Systems 119. Litigation relevant to regulation of novel and 132. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He Conference of the Parties to the WHO emerging nicotine and tobacco products. JX et al. Clinical characteristics of coronavirus Framework Convention on Tobacco Control. Geneva: World Health Organization; 2021. disease 2019 in China. New England Journal FCTC/COP/6/10 Rev.1. 1 September 2014. of Medicine. 2020;382(18):1708–1720. Moscow: World Health Organization; 2014. 120. Tobacco Tactics [website]. IQOS Use, “Switching” and “Quitting”: The Evidence. 133. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y 107. Conference of the Parties to the WHO Bath, UK: University of Bath; 2021 (https:// et al. Clinical features of patients infected Framework Convention on Tobacco Control. tobaccotactics.org/wiki/iqos-use-evidence/, with 2019 novel coronavirus in Wuhan, China. Decision FCTC/COP6/10. Control and accessed 3 July 2021). Lancet. 2020;395(10223):497–506. prevention of waterpipe tobacco products. Geneva: World Health Organization; 2014 121. WHO statement on heated tobacco products 134. Zhang JJ, Dong X, Cao YY, Yuan YD, Yang YB, (https://apps.who.int/gb/fctc/PDF/cop6/ and the US FDA decision regarding IQOS [news Yan YQ et al. Clinical characteristics of 140 FCTC_COP6(10) -en.pdf, accessed 21 July release]. Geneva: World Health Organization; patients infected with SARS-CoV-2 in Wuhan, 2021). 2020 (https://www.who.int/news/item/27- China. Allergy. 2020;75(7):1730–1741. 07-2020-who-statement-on-heated-tobacco- 108. WHO Framework Convention on products-and-the-us-fda-decision-regarding- 135. Gao F, Zheng KI, Wang X-B, Sun Q-F, Pan Tobacco Control. Geneva: World iqos, accessed 17 July 2021). K-H, Wang T-Y et al. Obesity is a risk factor Health Organization; 2003, updated for greater COVID-19 severity. Diabetes Care. 2004, 2005 (http://apps.who.int/iris/ 122. Goldenson NI, Leventhal AM, Simpson KA, 2020;43(7):e72-e74. bitstream/10665/42811/1/9241591013. Barrington-Trimis JL. A review of the use pdf?ua=1, accessed 3 July 2021). and appeal of flavored electronic cigarettes. 136. Finer N, Garnett SP, Bruun JM. COVID‐19 and Current Addiction Reports. 2019;6(2):98–113. obesity. Clinical Obesity. 2020;10(3). 109. Tobacco industry interference with tobacco control. Geneva: World Health Organization; 123. Felicione NJ, Ozga-Hess JE, Ferguson SG, Dino 137. Zheng Z, Peng F, Xu B, Zhao J, Liu H, J P 2008. G, Kuhn S, Haliwa I et al. Cigarette smokers’ et al. Risk factors of critical and mortal concurrent use of smokeless tobacco: dual COVID-19 cases: A systematic literature 110. The Israel Supreme Court, Tel Aviv Chamber use patterns and nicotine exposure. Tobacco review and meta-analysis. Journal of Infection. of Commerce v Israeli Knesset & Ors., HC Control. 2021;30(1):24–29. 2020;81(2):e16–125. 4657/19 and HC 1532/19. 2019. 124. McKee M, Daube M, Chapman S. E-cigarettes 138. Alraddadi BM, Watson JT, Almarashi A, 111. Ghebreyesus TA, Vazquez TR. Seeing through should be regulated. Medical Journal of Abedi GR, Turkistani A, Sadran M et al. Risk big tobacco’s smokescreen. In: Project Australia. 2016;204(9):331. factors for primary Middle East respiratory Syndicate [website]. New York: 2017. syndrome coronavirus illness in humans, Saudi 125. Hiscock R, Silver K, Zatoński M, Gilmore AB. Arabia, 2014. Emerging infectious diseases. 112. Matthes BL, Gilmore A. Needs of LMIC- Tobacco industry tactics to circumvent and 2016;22(1):49. based tobacco control advocates to counter undermine the menthol cigarette ban in the tobacco industry policy interference: insights UK. Tobacco Control. 2020;29 (e1):e138-e142. 139. Park J-E, Jung S, Kim A, Park J-E. MERS from semi-structured interviews. BMJ Open. transmission and risk factors: a systematic 2021;10(11) :e044710. 126. Branston JR, Hiscock R, Silver K, Arnott review. BMC Public Health. 2018;18(1):574. D, Gilmore AB. Cigarette-like cigarillo 113. STOP: A Global Tobacco Industry Watchdog introduced to bypass taxation, standardised 140. Kozak R, Prost K, Yip L, Williams V, Leis [website]. (tobhttps://exposetobacco.org/ packaging, minimum pack sizes, and JA, Mubareka S. Severity of coronavirus about/, accessed 3 July 2021). menthol ban in the UK. Tobacco Control. respiratory tract infections in adults admitted 2020;tobaccocontrol-2020-055700. to acute care in Toronto, Ontario. Journal of 114. E-cigarettes shaped like USB flash drives: Clinical Virology. 2020;126:104338. information for parents, educators, and health 127. Robertson L, Joshi A, Legg T, Wellock care providers. In: Smoking & Tobacco use G, Ray K, Evans-Reeves K. Exploring 141. Slama K, Chiang C, Enarson D, Hassmiller [website]. Atlanta, GA: Centers for Disease the Twitter activity around the eighth K, Fanning A, Gupta P et al. Tobacco and Control; 2020 (https://www.cdc.gov/tobacco/ meeting of the Conference of the Parties tuberculosis: a qualitative systematic basic_information/e-cigarettes/factsheet/ to the WHO Framework Convention review and meta-analysis. The International index.html, accessed 3 July 2021). on Tobacco Control. Tobacco Control. Journal of Tuberculosis and Lung Disease. 2020;tobaccocontrol-2020-055889. 2007;11(10):1049–1061. 115. E-cigarettes. In: Tobacco Tactics [website]. Bath, UK: University of Bath: 2021 (https:// 128. van der Eijk Y, Bero L, Malone RE. Philip 142. Baskaran V, Murray RL, Hunter A, Lim WS, tobaccotactics.org/wiki/e-cigarettes/, Morris International-funded “Foundation McKeever TM. Effect of tobacco smoking on accessed 2 July 2021, accessed 2 July 2021). for a Smoke-Free World”: analysing its the risk of developing community acquired claims of independence. Tobacco Control. pneumonia: A systematic review and meta- 116. Designed for addiction. How the tobacco 2019;28(6):712–718. analysis. PloS one. 2019;14(7):e0220204. industry has made cigarettes more addictive, more attractive to kids and even more deadly. 129. The Israel Supreme Court, E-Cig Ltd. v Ministry 143. van Zyl-Smit RN, Richards G, Leone FT. Washington, DC: Tobacco Free Kids; 2014 of Health, HCJ 6665/12,. 2014. Tobacco smoking and COVID-19 infection. (https://www.tobaccofreekids.org/assets/ The Lancet Respiratory Medicine. content/what_we_do/industry_watch/ 130. Patanavanich R, Glantz S. Successful 2020;8(7):664–665. product_manipulation/2014_06_19_ countering of tobacco industry efforts DesignedforAddiction_web.pdf, accessed to overturn Thailand’s ENDS ban. 144. Li X, Zhong X, Wang Y, Zeng X, Luo T, Liu 3 July 2021). Tobacco Control. 2020. doi: 10.1136/ Q. Clinical determinants of the severity of tobaccocontrol-2020-056058. COVID-19: a systematic review and meta- 117. Pisinger C, Godtfredsen N, Bender A. A analysis. PLoS One. 2021;16(5):e0250602. conflict of interest is strongly associated with 131. Wu Z, McGoogan JM. Characteristics of tobacco industry-favorable results, indicating and important lessons from the coronavirus 145. Smoking and COVID-19: scientific Brief. no harm of e-cigarettes. Preventive Medicine. disease 2019 (COVID-19) outbreak in China: Geneva: World Health Organization; 2020. 2019;119:124–131. Summary of a report of 72 314 cases from the Chinese Center for Disease Control and 146. Patanavanich R, Glantz SA. Smoking is 118. Gilmore AB, Braznell S. US regulator adds to Prevention. Journal of the American Medical associated with COVID-19 progression: confusion around heated tobacco products. Association. 2020;323(13):1239–1242. a meta-analysis. Nicotine and Tobacco British Medical Journal. 2020;370:m3528. Research. 2020;22(9):1653–1656.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 113 147. Gallus S, Lugo A, Gorini G. No double-edged 160. Filby S, van der Zee K, van Walbeek C. The 175. The health consequences of involuntary sword and no doubt about the relation temporary ban on tobacco sales in South exposure to tobacco smoke: a report of the between smoking and COVID-19 severity. Africa: lessons for endgame strategies. Surgeon General. Atlanta, GA: Centers for European Journal of Internal Medicine. Tobacco Control. 2021;0:1–7. Disease Control; 2006 (https://www.ncbi.nlm. 2020;77:33–35. nih.gov/books/NBK44324/pdf/Bookshelf_ 161. Berg CJ, Callanan R, Johnson TO, Schliecher NBK44324.pdf, accessed 21 July 2021). 148. Brake SJ, Barnsley K, Lu W, McAlinden NC, Sussman S, Wagener TL et al. Vape shop KD, Eapen MS, Singh Sohal S. Smoking and consumer activity during COVID-19 176. Tobacco smoke and involuntary smoking. upregulates angiotensin-converting enzyme-2 non-essential business closures in the USA. Lyon, France: International Agency for receptor: a potential adhesion site for novel Tobacco Control. 2020;0: 1–4. Research on Cancer; 2004. coronavirus SARS-CoV-2 (COVID-19). Journal of Clinical Medicine. 2020;9(3). 162. Lighting up the illicit market: Smokers’ 177. Johnson KC, Miller AB, Collishaw NE, Palmer responses to the cigarette sales ban in JR, Hammond SK, Salmon AG et al. Active 149. Chen DT, Kyriakos CN. Cigarette and South Africa. Cape Town: University of smoking and secondhand smoke increase e-cigarettes dual users, exclusive users and Cape Town; 2020. breast cancer risk: the report of the Canadian COVID-19: Findings from four UK birth cohort Expert Panel on Tobacco Smoke and Breast studies. International Journal of Environmental 163. Carreras G, Lugo A, Stival C, Amerio A, Cancer Risk (2009). Tobacco Control. Research and Public Health. 2021;18(8). Odone A, Pacifici R et al. Impact of COVID-19 2011;20(1). lockdown on smoking consumption in a 150. Russo P, Bonassi S, Giacconi R, Malavolta M, large representative sample of Italian adults. 178. Wipfli H, Avila-Tang E, Navas-Acien A, Kim Tomino C, Maggi F. COVID-19 and smoking: is Tobacco Control. 2021;0:1–8. S, Onicescu G, Yuan J et al. Secondhand nicotine the hidden link? European Respiratory smoke exposure among women and children: Journal. 2020;55(6). 164. Soerjomataram I, Ginsburg O, Steinberg J, Evidence from 31 countries. American Journal Canfell K, Hughes S, Sarich P et al. Smoking of Public Health. 2008;98(4):672–679. 151. Efficacy of nicotine in preventing COVID19 behaviour during the COVID19 pandemic. (in infection (NICOVID-PREV). National Institute press). 2021. 179. Fantuzzi G, Aggazzotti G, Righi E, Facchinetti of Health, 2021. F, Bertucci E, Kanitz S et al. Preterm delivery 165. Many smokers used lockdown to quit. In: and exposure to active and passive smoking 152. Simons D, Shahab L, Brown J, Perski O. The Eyewitness News [website] (https://ewn. during pregnancy: a case-control study from association of smoking status with SARS- co.za/2020/06/08/many-smokers-used- Italy. Paediatric and Perinatal Epidemiology. CoV-2 infection, hospitalization and mortality lockdown-to-quit-surveys, accessed 17 July 2007;21(3):194–200. from COVID-19: a living rapid evidence review 2021). with Bayesian meta-analyses (version 7). 180. Fantuzzi G, Vaccaro V, Aggazzotti G, Righi Addiction. 2021;116(6):1319–1368. 166. Zatonski M, Gilmore A Hird T. The two faces E, Kanitz S, Barbone F et al. Exposure to of the tobacco industry during the COVID-19 active and passive smoking during pregnancy 153. Haddad C, Bou Malhab S, Sacre H pandemic. Tobacco Control. 2020. and severe small for gestational age at Salameh P. Smoking and COVID-19: a term. Journal of Maternal-Fetal & Neonatal scoping review. Tobacco Use Insights. 167. Big tobacco is exploiting COVID-19 to Medicine. 2008;21(9):643–647. 2021;14:1179173x21994612. market its harmful products. In: Campaign for Tobacco-Free Kids [website]. Campaign 181. Anderson HR, Cook DG. Passive smoking 154. Horel S, Keyzer T. COVID-19: How harm- for Tobacco-Free Kids; 2021 (https://www. and sudden infant death syndrome: review reduction advocates and the tobacco industry tobaccofreekids.org/media/2020/2020_05_ of the epidemiological evidence. Thorax. capitalised on the pandemic to promote covid-marketing, accessed 3 July 2021). 1997;52(11) :1003–1009. nicotine. British Medical Journal. 2021;373. 168. STOP: A Global Tobacco Industry Watchdog 182. Law MR, Hackshaw AK. Environmental 155. Clancy L, Gallus S, Leung J, Egbe CO. Tobacco [website] (https://tobaccotactics.org/wiki/ tobacco smoke. British Medical Journal. and COVID-19: understanding the science and covid-19/, accessed 17 July 2021). 1996;52:22–34. policy implications. Tobacco Induced Diseases. 2020;18:1–4. 169. WHO report on the global tobacco epidemic 183. Gilbert SG, Miller E, Martin J, Abulafia 2008: The MPOWER package. Geneva: L. Scientific and policy statements on 156. Fernández E, Martínez C. Spain: COVID-19 World Health Organization; 2008. environmental agents associated with prompts smoking regulation in streets and neurodevelopmental disorders. Journal of terraces. 2020 [blog]. In: Tobacco Control 170. WHO report on the global tobacco epidemic Intellectual & Developmental Disability. [website]. 2020 (https://blogs.bmj.com/ 2009: Implementing smoke-free packages. 2010;35(2):121–128. tc/2020/09/05/spain-covid-19-prompts- Geneva: World Health Organization; 2009. smoking-regulation-in-streets-and-terraces/, 184. Leonardi-Bee J, Britton J, Venn A. secondhand accessed 17 July 2021). 171. MPOWER: a policy package to reverse the smoke and adverse fetal outcomes in tobacco epidemic. Geneva: World Health nonsmoking pregnant women: a meta- 157. El-Awa F, Fraser CP, Adib K, Hammerich A, Organization; 2008. analysis. Pediatrics. 2011;127(4):734–741. Abdel Latif N, Fayokun R et al. The necessity of continuing to ban tobacco use in public 172. Tajikistan STEPS Survey. Geneva; World Health 185. Hone T, Szklo A, Filippidis FT, Laverty AA, places post-COVID-19. Eastern Mediterranean Organization; 2016 (https://extranet.who. Satamini I, Been JV. Smokefree legislation Health Journal. 2020;26(6):630–632. int/ncdsmicrodata/index.php/catalog/270, and neonatal and infant mortality in Brazil: accessed 17 July 2021). longitudinal quasi-experimental study. 158. Ahmedabad tackles COVID-19 transmission Tobacco Control. 2020;29(3):312–9. with ban on smokeless tobacco products 173. China report on health hazards of smoking and spitting in public. Geneva: World Health 2020. Beijing; People’s Medical Publishing 186. Cains T, Cannata S, Poulos R, Ferson MJ, Organization; 2020. House: 2021. Stewart BW. Designated “no smoking” areas provide from partial to no protection from 159. Bhutan lifts decade long tobacco ban to 174. WHO Framework Convention on Tobacco environmental tobacco smoke. Tobacco prevent COVID-19 transmission. Addiction. Control, Guidelines for implementation: Control. 2004;13(1):17–22. 2020 (https://www.addictionjournal.org/ Article 5.3, Article 8, Articles 9 and 10, Article posts/bhutan-lifts-decade-long-tobacco-ban- 11, Article 12, Article 13, Article 14. Geneva: to-prevent-covid-19-transmission, accessed World Health Organization; 2013. 17 July 2021).
114 | WORLD HEALTH ORGANIZATION 187. Frazer K, Callinan JE, McHugh J, van Baarsel S, 197. Campaign for Tobacco-Free Kids [website]. 209. Jordan STEPS Survey. Geneva: World Health Clarke A, Doherty K et al. Legislative smoking Smoke-free laws do not harm business Organization; 2019 (https://www.moh.gov.jo/ bans for reducing harms from secondhand at restaurants and bars. Campaign for Echobusv3.0/SystemAssets/6209a77f-3767- smoke exposure, smoking prevalence and Tobacco-Free Kids; 2018 (https://www. 4c00-a1a0-262e082b9a3c.pdf, accessed tobacco consumption. Cochrane Database of tobaccofreekids.org/assets/factsheets/0144. 17 July 2021). Systematic Reviews. 2016(2):194. pdf, accessed 3 July 2021). 210. Chapman, S Liberman J. Ensuring smokers are 188. Mulcahy M, Evans DS, Hammond SK, Repace 198. The economics of tobacco and tobacco adequately informed: reflections on consumer JL, Byrne M. Secondhand smoke exposure control. Bethesda, MD: U.S. Department rights, manufacturer responsibilities, and and risk following the Irish smoking ban: an of Health and Human Services, National policy implications. Tobacco Control. assessment of salivary cotinine concentrations Institutes of Health, National Cancer Institute; 2005;14:II8–II13. in hotel workers and air nicotine levels in bars. and Geneva, CH: World Health Organization Tobacco Control. 2005;14(6):384–388. 2016 (https://cancercontrol.cancer.gov/brp/ 211. Kozlowski LT, Edwards BQ. “Not safe” is tcrb/monographs/monograph-21, accessed not enough: smokers have a right to know 189. Gan Q, Hammond SK, Jiang Y, Yang Y, Hu 3 July 2021). more than there is no safe tobacco product. TW. Effectiveness of a smoke-free policy in Tobacco Control. 2005;14 Suppl 2:ii3–7. lowering secondhand smoke concentrations 199. Fong GT, Hyland A, Borland R, Hammond in offices in China. Journal of Occupational D, Hastings G, McNeill A et al. Reductions 212. Committee on Economic, Social and Cultural and Environmental Medicine. 2008;50(5): in tobacco smoke pollution and increases in Rights. Report on the twenty-second, twenty- 570–575. support for smoke-free public places following third and twenty-fourth sessions, Supplement the implementation of comprehensive smoke- no. 2. New York and Geneva: United Nations; 190. Centers for Disease Control and Prevention. free workplace legislation in the Republic 2001. Reduced secondhand smoke exposure after of Ireland: findings from the ITC Ireland/UK implementation of a comprehensive statewide Survey. Tobacco Control. 2006;15:51–58. 213. Fathelrahman AI, Omar M, Awang R, Borland smoking ban. Morbidity and Mortality Weekly R, Fong GT, Hammond D et al. Smokers’ Report. 2007;56(28):705–708. 200. Global Burden of Disease [database]. responses toward cigarette pack warning Washington, DC: Institute of Health labels in predicting quit intention, stage 191. Smoke-free policies reduce smoking. Metrics; 2019 (https://extranet.who.int/ of change, and self-efficacy. Nicotine and In: Smoking and tobacco use [website]. ncdsmicrodata/index.php/catalog/270 IHME, Tobacco Research. 2009;11(3):248–53. Atlanta, GA: Centers for Disease Control; accessed 17 July 2021). 2020 (https://www.cdc.gov/tobacco/data_ 214. Ngo A, Cheng KW, Shang C, Huang J, statistics/fact_sheets/secondhand_smoke/ 201. The health benefits of smoking cessation: Chaloupka FJ. Global evidence on the protection/reduce_smoking/index.htm, a report of the Surgeon General. Rockville, association between cigarette graphic accessed 17 July 2021). MD: P.H.S. US Department of Health and warning labels and cigarette smoking Human Services, Centers for Disease Control, prevalence and consumption. International 192. Cheng KW, Glantz SA, Lightwood JM. Center for Chronic Disease Prevention and Journal of Environmental Research and Association between smokefree laws Health Promotion, and Office on Smoking Public Health. 2018;15(3). and voluntary smokefree-home rules. and Health; 1990 (https://profiles.nlm. American Journal of Preventive Medicine. nih.gov/spotlight/nn/catalog/nlm:nlmuid- 215. Li Z, Elton-Marshall T, Fong GT, Quah ACK, 2011;41(6):566–572. 101584932X37-doc, accessed 3 July 2021). Feng G, Jiang Y et al. Noticing cigarette health warnings and support for new health 193. Borland R. Tobacco health warnings and 202. Upspring WW, DiFranza JR. The loss of warnings among non-smokers in China: smoking-related cognitions and behaviours. autonomy over smoking in relation to lifetime findings from the International Tobacco Addiction. 1997;92(11) :1427–35. cigarette consumption. Addictive Behaviors. Control project (ITC) China survey. BMC 2010;35(1):14–18. Public Health. 2017;17(1):476. 194. Smoking in the home: attitudes and perceptions and the impact of the 203. Cohen S, Lichtenstein E, Prochaska JO, 216. Kamyab K, Nonnemaker JM, Farrelly MC. 2004 Irish smoking ban. Castlebar, Rossi JS, Gritz ER, Carr CR et al. Debunking Public support for graphic health warning County Mayo: Health Service Executive myths about self-quitting. Evidence from 10 labels in the U.S. American Journal of West; 2006 (https://www.lenus.ie/ prospective studies of persons who attempt Preventive Medicine. 2015;48(1):89–92. bitstream/handle/10147/44864/6524. to quit smoking by themselves. The American pdf?sequence=1&isAllowed=y, accessed Psychologist. 1989;44(11) :1355–65. 217. International Tobacco Control Policy 3 July 2021). Evaluation, P, FCTC Article 11: tobacco 204. Stead LF, Hartmann-Boyce J, Perera R, warning labels, in Evidence and 195. Campaign for Tobacco-Free Kids [website]. Lancaster T. Telephone counselling for recommendations from the ITC project. Smoke-free laws encourage smokers to quit smoking cessation. Cochrane Database Waterloo, Ontario: ITC; 2009. and discourage youth from starting. Campaign Systematic Reviews. 2013;12(8)CD002850. for Tobacco-Free Kids; 2018 (https://www. 218. Lempert LK, Glantz S. Packaging colour tobaccofreekids.org/assets/factsheets/0198. 205. Stead LF, Koilpillai P, Fanshawe TR, research by tobacco companies: the pack pdf, accessed 3 July 2021). Lancaster T. Combined pharmacotherapy as a product characteristic. Tobacco Control. and behavioural interventions for smoking 2017;26(3):307–315. 196. IARC handbooks of cancer prevention: cessation. Cochrane Database Systematic tobacco control. Volume 13: Evaluating the Reviews. 2016(3)CD008286. 219. Yong HH, Borland R, Cummings KM, Lindblom effectiveness of smoke-free policies. Lyon, EN, Li L, Bansal-Travers M et al. US smokers’ France: International Agency for Research 206. Whittaker R, McRobbie H, Bullen C, Rodgers beliefs, experiences and perceptions of on Cancer; 2009 (http://publications.iarc. A, Gu Y. Mobile phone‐based interventions different cigarette variants before and after fr/Book-And-Report-Series/Iarc-Handbooks- for smoking cessation. Cochrane Database of the FSPTCA ban on misleading descriptors Of-Cancer-Prevention/Evaluating-The- Systematic Reviews. 2016;10:4(4)CD006611. such as “light”, “mild”, or “low”. Nicotine & Effectiveness-Of-Smoke-free-Policies-2009, Tobacco Research. 2016;18(11) :2115–2123. accessed 3 July 2021). 207. An evaluation of the ‘Tuku Ifi Leva 2017’ anti- tobacco mass media campaign in the Kingdom 220. Falcone M, Bansal-Travers M, Sanborn of Tonga: Phase 2 Campaign. Sydney 2018 PM, Tang KZ, Strasser AA. Awareness of FDA-mandated cigarette packaging changes 208. Tonga STEPS Survey. Geneva: World Health among smokers of “light” cigarettes. Health Organization; 2017 Education Research. 2015;30(1):81–6.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 115 221. Borland R, Wilson N, Fong GT, Hammond 233. McAfee T, Davis K, Alexander RL Jr, Pechacek 245. Centers for Disease Control and Prevention. D, Cummings KM, Yong HH et al. Impact of TF, Bunnell R. Effect of the first federally Decline in smoking prevalence – New York graphic and text warnings on cigarette packs: funded US antismoking national media City. Morbidity and Mortality Weekly Report. findings from four countries over 5 years. campaign. Lancet. 2013;382:2003–2011. 2007;56(24):604–8. Tobacco Control. 2009;18(5):358–64. 234. Durkin S, Brennan E, Wakefield M. Mass 246. Henriksen, L. Comprehensive tobacco 222. Kowitt SD, Noar SM, Ranney LM, Goldstein media campaigns to promote smoking marketing restrictions: promotion, AO. Public attitudes toward larger cigarette cessation among adults: an integrative review. packaging, price and place. Tobacco Control. pack warnings: Results from a nationally Tobacco Control. 2012;21:127–138. 2012;21(2):147–53. representative U.S. sample. PLoS One. 2017. 235. Dunlop SM, Wakefield M, Kashima Y. The 247. Saffer H, Chaloupka F. The effect of tobacco 223. Noar SM, Hall MG, Francis DB, Ribisl KM, contribution of antismoking advertising advertising bans on tobacco consumption. Pepper JK, Brewer NT. Pictorial cigarette pack to quitting: intra- and interpersonal Journal of Health Economics. 2000;19(6): warnings: a meta-analysis of experimental processes. Journal of Health Communication. 1117–37. studies. Tobacco Control. 2016;25(3):341-54. 2008;13:250–266. 248. Kasza KA, Hyland AJ, Brown A, Siahpush M, 224. Hammond D. Health warning messages on 236. Bala MM, Lukasz S, Topor-Madry R, Cahill Yong H-H, McNeill AD et al. The effectiveness tobacco products: a review. Tobacco Control. K. Mass media interventions for smoking of tobacco marketing regulations on reducing 2011;20:327–337. cessation in adults. Cochrane Database smokers’ exposure to advertising and Systematic Review. 2013;6(CD004704). promotion: findings from the international 225. Francis DB, Mason N, Ross JC, Noar SM. Tobacco Control (ITC) four-country survey. Impact of tobacco-pack pictorial warnings on 237. Haghpanahan H, Mackay D, Pell JP, Bell International Journal of Environmental youth and young adults: a systematic review D, Langley T, Haw S. The impact of TV Research and Public Health. 2011;8(2): of experimental studies. Tobacco Induced mass media campaigns on calls to a 321–340. Diseases. 2019;17(41). national quitline and the use of prescribed nicotine replacement therapy: a structural 249. Blecher E. The impact of tobacco advertising 226. Strahan E, White K, Fong G, Fabrigar L, Zanna vector autoregression analysis. Addiction. bans on consumption in developing M, Cameron R. Enhancing the effectiveness 2017;112(7):1229–1237. countries. Journal of Health Economics. of tobacco package warning labels: a social 2008;27(4):930–942. psychological perspective. Tobacco Control. 238. Murukutla N, Bayly M, Mullin S, Cotter T, 2002;11(3):183–90. Wakefield M. Team IA-SARS. Male smoker 250. The tobacco industry and the health risks of and non-smoker responses to television smoking. Second report. In: www.parliament. 227. Noar SM, Francis DB, Bridges C, Sontag advertisements on the harms of secondhand UK [website]. London: UK Parliament; 2000 JM, Ribisl KM, Brewer NT. The impact of smoke in China, India and Russia. Health (https://publications.parliament.uk/pa/ strengthening cigarette pack warnings: Education Research. 2015;30(1):24–34. cm199900/cmselect/cmhealth/27/2707.htm, systematic review of longitudinal accessed 4 July 2021). observational studies. Social Science and 239. Bafunno D, Catino A, Lamorgese V, Del Medicine. 2016;164:118–129. Bene G, Longo V, Montrone M et al. Impact 251. Building blocks for tobacco control: of tobacco control intervenions on smoking a handbook. Geneva; World Health 228. Current cigarette smoking among adults in the initiation, cessation, and prevalence: a Organization: 2018. United States.In: Smoking and tobacco use systematic review. Journal of Thoracic [website]. Atlanta, GA: Centers for Disease Disease. 2020;12(7):3844–3856. 252. Saffer H. Tobacco advertising and promotion. Control; 2020 (https://www.cdc.gov/tobacco/ In: Tobacco control in developing countries, data_statistics/fact_sheets/adult_data/cig_ 240. DiFranza JR, Wellman RJ, Sargent JD, Jha P, Chaloupka FJ, Eds. Oxford: Oxford smoking/index.htm, accessed 17 July 2021). Weitzman M, Hipple BJ, Winickoff JP. Tobacco University Press; 2000. promotion and the initiation of tobacco 229. Turk T, Chaturvedi P, Murukutla N, Mallik V, use: assessing the evidence for causality. 253. Guidelines for implementation of Article Sinha P, Mullin S. Raw and real: an innovative Pediatrics. 2006; 117(6):e1237–48. 13: Tobacco advertising, promotion and communication approach to smokeless sponsorship. World Health Organization tobacco control messaging in low- and 241. Lovato C, Watts A, Stead LF. Impact of Framework Convention on Tobacco Control. middle-income countries. Tobacco Control. tobacco advertising and promotion on Geneva: World Health Organization; 2008. 2017;26(4):476–481. increasing adolescent smoking behaviours. Cochrane Database Syst Rev. 2011(10): 254. Cohen JE, Planinac L, Lavack A, Robinson 230. Reducing tobacco use: a report of the Surgeon Cd003439. D, O’Connor S, DiNardo J. Changes in retail General. Atlanta, GA: U.S. Department of tobacco promotions in a cohort of stores Health and Human Services, National Center 242. Lee S, Ling PM, Glantz SA. The vector of the before, during, and after a tobacco product for Chronic Disease Prevention and Health tobacco epidemic: tobacco industry practices display ban. American Journal of Public Promotion, Office on Smoking and Health; in low- and middle-income countries. Cancer Health. 2011;101(10):1879–81. 2000 (https://www.cdc.gov/tobacco/data_ Causes Control. 2012;23 Suppl 1:117–29. statistics/sgr/2000/complete_report/pdfs/ 255. Carter OB, Phan T, Mills BW. Impact of a fullreport.pdf, accessed 3 July 2021). 243. Gender, women, and the tobacco epidemic. point-of-sale tobacco display ban on smokers’ Geneva: World Health Organization; spontaneous purchases: comparisons from 231. The role of the media in promoting 2010 (http://apps.who.int/iris/bitstream/ post-purchase interviews before and after the and reducing tobacco use. Bethesda, handle/10665/44342/9789241599511_eng. ban in Western Australia. Tobacco Control. MD: National Institutes of Health; pdf?sequence=1&isAllowed=y, accessed 2015;24(e1):e81–6. 2008 (https://www.javeriana.edu.co/ 4 July 2021). documents/245769/3062153/rol_de_los_ 256. Lee JGL, Henriksen L, Myers AE, Dauphinee medios_tabaquismo_ingles.pdf/8c41a392- 244. Wellman RJ, Sugarman DB, DiFranza JR, AL, Ribisl KM. A systematic review of dc0b-4b38-b4ef-870053747054, accessed Winickoff JP. The extent to which tobacco store audit methods for assessing tobacco 3 July 2021). marketing and tobacco use in films contribute marketing and products at the point of sale. to children’s use of tobacco: a meta-analysis. Tobacco Control. 2014;23(2):98. 232. Siegel M. Mass media antismoking campaigns: Archives of Pediatric Adolescent Medicine. a powerful tool for health promotion. Annals 2006;160(12):1285–96. of Internal Medicine. 1998;129(2):128–132.
116 | WORLD HEALTH ORGANIZATION 257. Robertson L, Cameron C, McGee R, 269. Tackling NCDs: “Best buys” and other Marsh L, Hoek J. Point-of-sale tobacco recommended interventions for the prevention promotion and youth smoking: a meta- and control of noncommunicable diseases. analysis. Tobacco Control. 25. 10.1136/ Geneva: World Health Organization; tobaccocontrol-2015-052586. 2017 (https://apps.who.int/iris/bitstream/ handle/10665/259232/WHO-NMH-NVI-17.9- 258. Spanopoulos D, Britton J, McNeill A, eng.pdf?sequence=1, accessed 4 July 2021) Ratschen E, Szatkowski L. Tobacco display and brand communication at the point of 270. Saving lives, spending less: a strategic sale: implications for adolescent smoking response to noncommunicable diseases. behaviour. Tobacco Control. 2014;23:64–69. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/bitstream/ 259. Fooks GJ, Gilmore AB, Smith KE, Collin handle/10665/272534/WHO-NMH-NVI-18.8- J, Holden C, Lee K. Corporate social eng.pdf?ua=1, accessed 4 July 2021). responsibility and access to policy elites: an analysis of tobacco industry documents. PLoS 271. Earmarked tobacco taxes: lessons Med. 2011; 8(8):e1001076. learnt from nine countries. Geneva: World Health Organization 2016 260. Ribisl KM, Jo C. Tobacco control is (https://apps.who.int/iris/bitstream/ losing ground in the Web 2.0 era: handle/10665/206007/9789241510424_eng. invited commentary. Tobacco Control. pdf, accessed 4 July 2021). 2012;21(2):145–146. 272. Sin tax reform in the Philippines: transforming 261. Request for Investigative and Enforcement public finance, health, and governance for Action to Stop Deceptive Advertising Online. more inclusive development. Washington, Campaign for Tobacco-Free Kids, American DC: World Bank Group; 2016 (http:// Academy of Family Physicians, American documents.worldbank.org/curated/ Academy of Pediatrics, American Cancer en/638391468480878595/pdf/106777-PUB- Society Cancer Action Network, American PUBLIC-PUBDATE-7-26-2016.pdf, accessed Heart Association, American Lung Association 4 July 2021) et al., 2018. 273. Tobacco price and taxation: ITC cross-country 262. Freeman B. New media and tobacco control. comparison report. Waterloo, Canada: Tobacco Control. 2012;21:139–144. International Tobacco Control; 2012
263. Texting, social networking popular worldwide. 274. Fiscal policy: how to design and enforce In: Pew Research Center [website]. 2012 tobacco excises? Washington, DC: (http://www.pewglobal.org/2011/12/20/ International Monetary Fund Fiscal Affairs global-digital-communication-texting-social- Department; 2016 (https://www.imf. networking-popular-worldwide, accessed org/external/pubs/ft/howtonotes/2016/ 4 July 2021). howtonote1603.pdf)
264. Social networking popular across globe. 275. Confronting illicit tobacco trade: a In: Pew Research Center 2012 [website] global review of country experiences. (http://www.pewglobal.org/2012/12/12/ Washington, DC: The World Bank; 2019 social-networking-popular-across-globe. (http://documents.worldbank.org/curated/ webcite, accessed 4 July 2021). en/677451548260528135/Confronting-Illicit- Tobacco-Trade-a-Global-Review-of-Country- 265. Venezuela, Global Youth Tobacco Survey Experiences, accessed 4 July 2021) 2019. 276. Reddy KS, Yadav A, Arora M, Nazar GP. 266. Task force on fiscal policy for health. Health Integrating tobacco control into health and taxes to save lives: employing effective development agendas. Tobacco Control. excise taxes on tobacco, alcohol, and sugary 2012;21:281–286. beverages. New York, NY: Bloomberg Philanthropies; 2019. 277. Tobacco use: equity and social determinants. Geneva: World Health Organization; 267. Scaling up action against noncommunicable 2010 (http://apps.who.int/iris/ diseases: How much will it cost? Geneva: bitstream/10665/44289/1/9789241563970_ World Health Organization; 2011 (https:// eng.pdf, accessed 4 July 2021) www.who.int/nmh/publications/cost_of_ inaction.pdf, accessed 4 July 2021).
268. IARC handbooks of cancer prevention: tobacco control. Volume 14: Effectiveness of tax and price policies for tobacco control. Lyon, France: International Agency for Research on Cancer; 2011 (https:// publications.iarc.fr/_publications/media/ download/4018/05229a5e57f58b0b f51364dd0f3329d45c898839.pdf, accessed 4 July 2021).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 117 118 | WORLD HEALTH ORGANIZATION TECHNICAL NOTES TECHNICAL NOTE I Evaluation of existing policies and compliance TECHNICAL NOTE II Smoking prevalence in WHO Member States TECHNICAL NOTE III Tobacco taxes in WHO Member States
ANNEXES ANNEX I Regional summary of MPOWER measures ANNEX II Electronic Nicotine Delivery Systems ANNEX III Year of highest level of achievement in selected tobacco control measures ANNEX IV Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world ANNEX V Status of the WHO Framework Convention on Tobacco Control and of the Protocol to Eliminate Illicit Trade in Tobacco Products
WEB ANNEXES WEB ANNEX VI: Global tobacco control policy data WEB ANNEX VII: Country profiles WEB ANNEX VIII: Tobacco tax revenues WEB ANNEX IX: Tobacco taxes, prices and affordability WEB ANNEX X: Age-standardized prevalence estimates of tobacco use, 2019 WEB ANNEX XI: Country-provided prevalence data WEB ANNEX XII: Maps on global tobacco control policy data
COVID-19 and the WHO report on the global tobacco epidemic, 2021
The WHO report on the global We also note that comparisons of their valuable time and resources tobacco epidemic, 2021 requires the latest data to previous years to ensuring this report could be the coordinated inputs of hundreds will need to take into account the published on time. Many people of public health specialists. It is exceptional circumstances during involved in the report have suffered important to note, therefore, that 2020 that have both accelerated from COVID-19 directly, had to production of this report faced progress in tobacco control in some care for family or friends during unique limitations. Many country- parts and slowed it down in others. this difficult time, and/or have lost level focal points in tobacco For instance, a number of countries loved ones. control faced significant capacity have managed to strengthen their We dedicate this report to all those challenges over the period of tobacco control legislation during we lost to COVID-19. data collection and validation that time. It is beyond the scope of because they had to take on this report to analyse the unique additional COVID-19 response context of each country. functions, therefore some valuable We want to take this opportunity information or refinements of our to thank all those who offered analyses may have been missed.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 119 TECHNICAL NOTE I EVALUATION OF EXISTING POLICIES AND COMPLIANCE
This report provides summary indicators ■ For P (protect people from tobacco ■ For R (raise taxes on tobacco): the of country achievements for each smoke), W (warn about the dangers prices of the most sold brand of of the MPOWER measures, and the of tobacco) and E (enforce bans cigarettes, the cheapest brand and methodology used to calculate each on tobacco advertising, promotion a premium brand were collected indicator is described in this Technical and sponsorship): original tobacco through regional data collectors. Note. To ensure consistency and control legislation (including Information on the taxation of comparability, the data collection and regulations) adopted in all Member cigarettes (and when possible, most analysis methodology used in this States that relate to smoke-free commonly used other smoked and report are largely based on previous environments, packaging and smokeless tobacco products) and editions of the report. Some details of labelling measures and tobacco revenues from tobacco taxation was the methodology employed in earlier advertising, promotion and collected from ministries of finance. reports, however, have been revised sponsorship. Tobacco control laws Technical Note III provides the and strengthened for the present and regulations as well as product detailed methodology used. report. Where revisions have been regulations are also the sources Based on these sources of information, made, data from previous reports have of data for ENDS and ENNDS. WHO assessed each indicator as of been re-analysed so that results are In cases where a law had been 31 December 2020. Exceptions to this comparable across years. adopted by 31 December 2020 cut-off date were tobacco product but had not yet entered into force, This edition of the report includes for prices and taxes (cut-off date 31 July the respective law was assessed the first time data on ENDS and ENNDS, 2020) and anti-tobacco mass media and data were reported with therefore the methodology used for campaigns (cut-off date 30 June 2020). an asterisk denoting “Provision the data related to these products was adopted but not implemented added throughout the Technical Notes. by 31 December 2020”. In cases where a law had been Data validation adopted but not yet the Data sources implementing regulations, data For each country, every data point for were reported with the asterisk which legislation was the source was Data were collected using the “Regulations are pending”. assessed by two expert staff from following sources: two different WHO offices, generally ■ For W (mass media): data on one from WHO headquarters and ■ For all areas: official reports from anti-tobacco mass media campaigns the other from the respective WHO WHO FCTC Parties to the Conference were obtained from Member States. Regional Office. Any inconsistencies of the Parties (COP) and their In order to avoid unnecessary were reviewed by the two WHO expert accompanying documentation.1 data collection, WHO conducted staff involved and, if needed, by a third ■ For M (monitoring): tobacco a screening for anti-tobacco mass expert staff member not yet involved prevalence surveys not reported media campaigns in all WHO Country in the appraisal of the legislation. under the COP reporting mechanism Offices. In countries where potentially Disagreements in the interpretation were collected mainly through eligible mass media campaigns of the legislation were resolved by: WHO Regional and WHO Country were identified, focal points in each (i) checking the original texts of the Offices. Technical Note II provides country were contacted for further legislation; (ii) trying to obtain consensus further details. information on these campaigns, from the two expert staff involved in and data on eligible campaigns were the data collection; (iii) trying to obtain gathered and systematically recorded. clarification from judges or lawyers in ■ For O (offer help to quit tobacco the concerned country; and (iv) the use): data not reported under the decision of the third expert in cases COP reporting mechanism were where differences remained. Data were collected mainly through WHO also checked for completeness and Regional and WHO Country Offices. logical consistency across variables.
120 | WORLD HEALTH ORGANIZATION report or according to changes in the ■ whether the youth and adult Data sign-off indicator methodology. All income populations were surveyed through groups used for this report derive school-based and household Final, validated data for each country from the World Bank income-group population-based surveys respectively. were sent to the respective governments classification published on 1 July 2020 for review and sign-off. To facilitate Surveys were considered recent if by the World Bank.3 Upper-middle review by governments, a summary conducted in the past 5 years. For and lower-middle income groups are sheet was generated for each country this report, this means 2015 or later. combined into one group for this report. and was sent for review prior to the Surveys were considered representative close of the report database. In cases When country or population totals for only if a scientific random sampling where national authorities requested MPOWER measures are referred to method was used to ensure nationally data changes, the requests were collectively in the analysis section of representative results. (Although they assessed by WHO expert staff according this report, only the implementation provide useful information, subnational to both the legislation/materials and of tobacco control policies (smoke-free surveys or national surveys of specific the clarification shared by the national legislation, cessation services, warning population groups provide insufficient authorities, and data were updated or labels, advertising, promotion and information to enable tobacco control left unchanged. In cases where national sponsorship bans, and tobacco taxes) action for the total population.) Surveys authorities explicitly did not agree with is included in these totals. were considered periodic if the same survey or a survey using the same or the data assessment, this is specifically Monitoring of tobacco use and similar questions was repeated at least noted in the annex tables. Further details anti-tobacco mass media campaigns once every 5 years. The following about the data processing procedure are are reported separately. available from WHO. definitions were applied for youth and adult surveys: Correction to previously Youth surveys: school-based surveys Data analysis of students aged 13–15 years or published data other age range encountered during It is important to note that data about secondary-level school. The questions The 2018 data published in the last laws reflect the status of legislation asked in the surveys should provide report were reviewed, and about 3% of adopted by 31 December 2020 that indicators that are consistent with those data points were corrected. The full set has a stated date of effect and is not specified in the Global Youth Tobacco of MPOWER data revised for all years undergoing a legal challenge that could Survey questionnaires and manuals. back to 2007 is available in the WHO impact the date of implementation. Global Health Observatory at https:// Adult surveys: population-based Data from laws not in effect by 31 www.who.int/data/gho/data/themes/ surveys that can provide indicators December 2020 have a footnote stating theme-details/GHO/tobacco-control. for adults aged 15 years and over (or this. The summary measures developed another age range starting around for this report are the same as those 15 and including people older than used for the 2019 report. 15), consistent with those specified The report provides analysis of progress Monitoring of tobacco use in the Global Adult Tobacco Survey made between 2018 and 2020, and and prevention policies questionnaires and manuals. between 2007 and 2020 using the latest The groupings for the Monitoring assessment of the status of measures The strength of a national tobacco indicator are listed below. in each year so that the results are surveillance system is assessed by the comparable across years. For R, the frequency and periodicity of nationally representative youth and adult surveys No known data or no recent* data or earliest comparable data are 2008 and data that are not both recent* and in countries. Countries are grouped in for mass media, data are available only representative** the top Monitoring category when all from 2010. To calculate the change Recent* and representative** in the percentage of the population criteria listed below are met for both data for either adults or youth covered by each policy or measure over youth and adult surveys: Recent* and representative** data for both adults and youth time, population estimates for the year ■ whether a survey was carried 20192 were used. Using a static year out recently; Recent*, representative** and periodic*** data for both adults eliminates the effect of population ■ whether the survey was representative and youth growth when measuring change over of the country’s population; * Data from 2015 or later. time. Indicators from previous years ** Survey sample representative of the national have been recalculated, according to ■ whether a similar survey was repeated population. *** Collected at least every 5 years. legislation/materials received after the within 5 years (periodic); and assessment period of the respective
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 121 Owing to the difficulty of running Groupings for the smoke-free population or school-based national legislation indicator are based on Tobacco dependence surveys during the COVID-19 pandemic, the number of places where indoor treatment countries who were at the highest smoking is completely prohibited. level of achievement in the previous Countries with no complete smoking The indicator of achievement in report have not been downgraded in ban at national level but where at least treatment for tobacco dependence this report. 90% of the population is covered by is based on whether the country complete subnational smoke-free laws has available: are grouped in the top category. ■ nicotine replacement therapy (NRT); Smoke-free legislation The groupings for the smoke-free ■ smoking cessation support; legislation indicator are listed below. ■ reimbursement for any of the above; There is a wide range of places and and institutions that can be made Not reported ■ a national toll-free quit line. smoke-free by law. Smoke-free Complete absence of bans, or up to two legislation can be in place at the public places completely smoke-free Despite the low cost of quit lines, national or subnational level. The Three to five public places completely few low- or middle-income countries smoke-free report includes data based on national have implemented such programmes. legislation, and legislation in subnational Six to seven public places completely smoke-free Thus, national toll-free quit lines are jurisdictions where available and where included as a qualification only for All public places completely smoke- national laws are incomplete. The free (or at least 90% of the population the highest category. Reimbursement assessment of subnational smoke- covered by complete subnational for tobacco dependence treatment free legislation includes first-level smoke-free legislation) is considered only for the top two administrative subdivisions of a country, categories to take restricted national as listed in ISO3166. Subnational data budgets of many lower-income reported in Annex VI only reflect In addition to the data used for the countries into consideration. the content of the subnational laws. above groupings of the smoke-free The top three categories reflect varying Provisions covered by national legislation legislation indicator, other related levels of government commitment to are indicated by an informative note data such as information on fines and the provision of nicotine replacement next to the subnational data. In enforcement were collected and are therapy and cessation support. cases where the status of smoke-free reported in Annex VI. legislation is not reported for some or The groupings for the tobacco A number of countries include all subnational jurisdictions, we assume dependence treatment indicator are exceptions to their smoke-free law that the existing national law applies. listed below. allow for the provision of designated Legislation was assessed to determine smoking rooms (DSRs) in certain whether smoke-free laws provided Not reported public places and workplaces. This for a complete4 indoor smoke-free is reported as a “No”. For the small None environment at all times, in all the number of countries where DSRs are NRT* and/or some cessation facilities of each of the following services** (neither cost-covered) allowed under “very strict technical eight places: 5 NRT* and/or some cessation services** requirements”, this is reported in the (at least one of which is cost-covered) ■ health-care facilities; Annex tables as an asterisk instead of National quit line, and both NRT* ■ educational facilities other than a “Yes”. If DSRs are allowed but the and some cessation services** universities; very strict requirements are missing or (cost-covered) not mentioned in the legislation, this * Nicotine replacement therapy. ■ universities; is reported as a “No”. The groupings ** Smoking cessation support available in any of the ■ governmental facilities; following places: health clinics or other primary care for smoke-free laws treat an asterisk facilities, hospitals, office of a health professional, the ■ indoor offices and workplaces not the same as a “No”, because a law community or other settings. considered in any other category; that allows DSRs in any form does not ■ restaurants or facilities that serve provide complete protection. mostly food; In addition to data used for the grouping of the tobacco dependence treatment ■ cafés, pubs and bars or facilities that serve mostly beverages; indicator, other related data such as information on countries’ essential ■ public transport. medicines lists, etc. were collected and are reported in Annex VI.
122 | WORLD HEALTH ORGANIZATION The groupings for the health warnings In order for a country to appear in Warning labels on indicator are listed below. this report as having introduced plain tobacco packaging packaging, the following criteria Data not reported (established by WHO FCTC Article 13 The section of the report that No warnings or small warnings 1 guidelines) are requested by a law and assesses each country’s legislation Medium size warnings 2 missing some3 the implementing rules: on health warnings includes the or many 4 appropriate characteristics5 6 4 ■ black and white or two other following information about OR large warnings missing many appropriate characteristics5 contrasting colours, as prescribed cigarette package warnings: Medium size warnings 2 with all by national authorities; ■ whether specific health warnings appropriate characteristics5 OR large ■ nothing other than a brand are mandated; warnings6 missing some 3 appropriate characteristics 5 name, a product name and/or ■ the mandated size of the warnings, Large warnings 6 with all appropriate manufacturer’s name, contact as a percentage of the front and characteristics5 details and the quantity of product back of the cigarette package; 1 Average of front and back of package is less in the packaging, without any logos than 30%. or other features apart from health ■ whether the warnings appear on 2 Average of front and back of package is between warnings, tax stamps and other individual packages as well as on 30 and 49%. any outside packaging and labelling 3 One to three. government-mandated information 4 Four or more. or markings; used in retail sale; 5 Appropriate characteristics: ■ specific health warnings mandated; ■ ■ whether the warnings describe prescribed font style and size for the ■ appearing on individual packages as well as above elements; specific harmful effects of tobacco on any outside packaging and labelling used use on health; in retail sale; ■ standardized shape, size and ■ describing specific harmful effects of tobacco materials: ■ whether the warnings are large, use on health; clear, visible and legible (e.g. ■ are large, clear, visible and legible ■ there should be no advertising or specific colours and font styles (e.g. specific colours and font style and sizes are mandated); promotion inside or attached to the and sizes are mandated); ■ rotate; package or on individual cigarettes ■ whether the warnings rotate; ■ include pictures or pictograms; or other tobacco products. ■ written in (all) the principal language(s) Countries with a law requiring plain ■ whether the warnings are written of the country. packaging but with no implementing in (all) the principal language(s) 6 Average of front and back of the package is of the country; at least 50%. rules or regulations yet adopted, will not be reported as having introduced ■ whether the warnings include plain packaging but will have the pictures or pictograms. footnote “Regulations are pending” In addition to the data about cigarettes The size of the warnings on both added in the report. This is also the used for the grouping of the health the front and back of the cigarette case for countries that have required warnings indicator, data about pack were averaged to calculate health warnings by law without having other smoked tobacco products and the percentage of the total pack yet issued the proper texts and/or smokeless tobacco products, as well surface area covered by warnings. images by decree, rule, regulation, etc. as other related data such as the This information was combined appearance of the quit line number, with the warning characteristics the requirement for plain packaging, to construct the groupings for etc. were collected and are reported Anti-tobacco mass the health warnings indicator. in Annex VI. media campaigns Plain packaging (also called Countries undertake communication standardized packaging) is defined by activities for many reasons, including WHO FCTC Article 11 guidelines as improving public relations, creating a measure “to restrict or prohibit the attention for an issue, building support use of logos, colours, brand images or for public policies, and prompting promotional information on packaging behaviour change. Anti-tobacco other than brand names and product communication campaigns, which are names displayed in a standard colour a core tobacco control intervention, and font style”. must have specified features in order
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 123 to be minimally effective: they must 5. The implementing agency worked Country-level achievements in banning be of sufficient duration and must with journalists to gain publicity or tobacco advertising, promotion and be designed to effectively support news coverage for the campaign. sponsorship were assessed based on tobacco control priorities, including whether the bans covered the following 6. Process evaluation was undertaken increasing knowledge, changing social types of advertising: to assess how effectively the norms, promoting cessation, preventing campaign had been implemented. ■ national television and radio; tobacco uptake, and increasing support for good tobacco control policies. 7. An outcome evaluation process ■ local magazines and newspapers; was implemented to assess With this in mind, and consistent with ■ billboards and outdoor advertising; campaign impact. the definition of “anti-tobacco mass ■ point of sale (indoor); media campaigns” in the last report, 8. The campaign was aired on only mass media campaigns that were: television and/or radio. ■ free distribution of tobacco products (i) designed to support tobacco control; in the mail or through other means; The groupings for the mass media (ii) at least 3 weeks in duration and campaigns indicator are listed below. ■ promotional discounts; (iii) implemented between 1 July 2018 ■ non-tobacco products identified and 30 June 2020 were considered Data not reported eligible for analysis. For the sake of with tobacco brand names No national campaign conducted 6 logistical feasibility and cross-country between July 2018 and June 2020 (brand stretching); comparability, only national-level with a duration of at least 3 weeks ■ brand names of non-tobacco campaigns were considered eligible. National campaign conducted with products used for tobacco products one to four appropriate characteristics Consistent with the last report and to (brand sharing);7 enable greater accuracy, materials from National campaign conducted with ■ appearance of tobacco brands campaigns had to be submitted and five to six appropriate characteristics, or with seven characteristics excluding (product placement) or tobacco verified based on the eligibility criteria airing on television and/or radio products in television and/or films; for all countries. National campaign conducted ■ sponsorship (contributions and/or Eligible campaigns were assessed with at least seven appropriate characteristics including airing publicity of contributions). according to the following characteristics, on television and/or radio which signify the use of a comprehensive The first four types of advertising communication approach: listed are termed “direct” advertising, and the remaining six are termed 1. The campaign was part of a “indirect” advertising. Complete bans comprehensive tobacco control Bans on advertising, on tobacco advertising, promotion and programme. promotion and sponsorship sponsorship usually start with bans on 2. Before the campaign, research was The report includes data on legislation direct advertising in national media and undertaken or reviewed to gain in national as well as subnational progress to bans on indirect advertising a thorough understanding of the jurisdictions. The assessment of as well as promotion and sponsorship. target audience. subnational legislation on advertising, The basic distinction for the two 3. Campaign communication materials promotion and sponsorship bans lowest groups is whether bans cover were pre-tested with the target includes first-level administrative national television, radio and print audience and refined in line with subdivisions as listed in ISO3166. media or not, and the remaining campaign objectives. Subnational data reported in Annex VI groups were constructed based on only reflect the content of subnational 4. Air time (radio, television) how comprehensively the law covers laws. Provisions covered by national and/or placement (billboards, print bans of other forms of direct and legislation are indicated by an advertising, etc.) were obtained indirect advertising included in the informative note next to the subnational by purchasing or securing it using questionnaire. In cases where the data. In cases where the status of either the organization’s own law did not explicitly address cross- advertising, promotion and sponsorship internal resources or an external border advertising, it was interpreted legislation is not reported for some or all media planner or agency (this that advertising at both domestic and subnational jurisdictions, we assume the information indicates whether the international levels was covered by existing national law applies. campaign adopted a thorough the ban only if advertising was totally media planning and buying process banned at national level. to effectively and efficiently reach its target audience).
124 | WORLD HEALTH ORGANIZATION The groupings for the bans on The groupings for the affordability advertising, promotion and sponsorship Tobacco taxes indicator are listed below. Please refer indicator are listed below. Countries to Technical Note III for more details. Countries are grouped according to the where at least 90% of the population percentage contribution of all tobacco were covered by subnational Cigarettes less affordable – per capita taxes to the retail price of a pack of 20 GDP needed to buy 2000 cigarettes legislation completely banning tobacco YES of the most popular brand of cigarettes. of the most sold brand increased on advertising, promotion and sponsorship Taxes assessed include excise tax, value average between 2010 and 2020 are grouped in the top category. added tax (or sales taxes), import duty Cigarettes more affordable – per capita GDP needed to buy 2000 Data not reported (when the cigarettes were imported) NO cigarettes of the most sold brand Complete absence of ban, or ban that and any other taxes levied. In the case declined on average between 2010 does not cover national television (TV), of countries where different levels of and 2020 radio and print media taxes applied to cigarettes are based No trend change in affordability of Ban on national TV, radio and print on length, quantity produced, or type cigarettes since 2010 media only (e.g. filter vs. non-filter), only the rate Insufficient data to conduct a trend ... Ban on national TV, radio and print that applied to the most popular brand analysis media as well as on some (but not all) other forms of direct* and/or is used in the calculation. indirect** advertising Given the lack of information on Ban on all forms of direct* and country and brand-specific profit indirect**advertising (or at least National tobacco 90% of the population covered by margins of retailers and wholesalers, subnational legislation completely their profits were assumed to be control programmes banning tobacco advertising, zero (unless provided by the national Classification of countries’ national promotion and sponsorship) data collector). tobacco control programmes is based * Direct advertising bans: ■ national television and radio; The groupings for the tobacco tax on the existence of a national agency ■ local magazines and newspapers; indicator are listed below. Please refer with responsibility for tobacco control ■ billboards and outdoor advertising; objectives. Countries with at least five ■ point of sale (indoor). to Technical Note III for more details. ** Indirect advertising bans: full-time equivalent staff members ■ free distribution of tobacco products in the mail Data not reported working at the national agency with or through other means; < 25% of retail price is tax responsibility for tobacco control meet ■ promotional discounts; ≥ 25% and < 50% of retail price is tax the criteria for the highest group. ■ non-tobacco goods and services identified with tobacco brand names (brand stretching); ≥ 50% and < 75% of retail price is tax The groupings for the national ■ brand names of non-tobacco products used for ≥ 75% of retail price is tax tobacco control programme indicator tobacco products (brand sharing); are listed below. ■ appearance of tobacco brands (product placement) or tobacco products in television and/or films; Data not reported ■ sponsorship (contributions and/or publicity of No national agency for tobacco control contributions). Trend in affordability of Existence of national agency with the most sold brand of responsibility for tobacco control cigarettes objectives with no or fewer than five In addition to the data used for the full-time equivalent staff members grouping of the bans on advertising, The affordability of cigarettes was Existence of national agency with promotion and sponsorship indicator, computed as the percentage of per responsibility for tobacco control other related data, such as bans on capita GDP required to purchase 2000 objectives and at least five full-time internet sales or on display of tobacco cigarettes of the most popular brand equivalent staff members products at points of sale were collected in each year of this report from 2010 and are reported in Annex VI. to present. The least-squares annual growth rate of affordability was computed by fitting a linear regression trend line to the logarithmic values of the affordability measure.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 125 The questions used for the groupings ■ a health professional (e.g. physician, Data collected and reported of the P,W and E measures described nurse, pharmacist or dentist) for ENDS and ENNDS in earlier were all assessed, and other specializing in tobacco-related relation to the P, W and E related data such as minimum sale conditions; age, or regulation of flavours, were ■ a staff member of a public health measures also collected and some of these are university department; reported in Annex II. For the first time ever, this report ■ the tobacco control focal point of includes PWE data collected about the WHO Country Office. ENDS and ENNDS. For P, W and E related data, the methodology used to Compliance assessment The experts performed their assessments collect and validate the data as well as independently. Average scores were the criteria used, were identical to those Compliance with national and calculated by WHO from the five described earlier in this Technical Note. comprehensive subnational individual assessments by assigning two However, no subnational legislation smoke-free legislation as well as points for highly enforced policies, one was assessed for these products (only with advertising, promotion and point for moderately enforced policies national legislation) and no compliance sponsorship bans was assessed by up and no points for minimally enforced data were collected. to five national experts, who scored policies, with a potential minimum of 0 the compliance in these two areas and maximum of 10 points in total from Specifications on data about as “minimal”, “moderate” or “high”. these five experts. ENDS and ENNDS These five experts were selected The compliance assessment was according to the following criteria: In terms of product regulation, ENDS obtained for legislation adopted by 1 and ENNDS were categorized based ■ person in charge of tobacco April 2020. For countries with more on provisions in national legislation prevention in the country’s recent legislation, compliance data are or regulations. For countries where ministry of health, or the most reported as “not applicable”. the sale of ENDS and ENNDS is senior government official in The compliance assessments are listed banned, we have nonetheless charge of tobacco control or in Annex VI. Annex I summarizes reported on regulations relating to tobacco-related conditions; this information. Compliance scores their use, advertising, promotion, and ■ the head of a prominent are represented separately from sponsorship. For W and E, a distinction nongovernmental organization the grouping (i.e. compliance is not was made between the regulation dedicated to tobacco control; included in the calculation of the applicable to the electronic devices grouping categories). and the one applicable to the e-liquids.
126 | WORLD HEALTH ORGANIZATION Background chapters searched include PubMED and link between smoking and Scopus and search terms used COVID-19? This section of the All background chapters were included ‘tobacco’, “smoking”, chapter was informed by the developed as brief summaries of “coronavirus”, “COVID”, “policies”, literature review described the topic areas covered and are “tobacco control”, “law” and above as well as the experience not intended to be comprehensive “interventions”. Three main of the WHO supporting reviews of the existing literature. questions were explored: countries during the pandemic. All recommendations presented This is not an exhaustive review ■ What is the link between are based upon pre-existing of all country approaches and is tobacco use and COVID-19? Member State agreements or not intended to provide policy With regard to the question published technical guidance. guidance or recommendations. of the relationship between COVID-19 and tobacco: tobacco use and COVID-19 ■ How has the tobacco industry outcomes, systematic reviews exploited the crisis to further the links identified in the literature their commercial ends? Our This chapter is intended to provide search were reviewed. WHO partners at the University a brief overview of the impact has commissioned an umbrella of Bath, STOP Initiative, are the COVID-19 pandemic has had systematic review of this continuously monitoring on tobacco users and tobacco literature (see below) and the industry interference. Again, control. The chapter is based upon researchers leading this work the information provided here literature provided by partners reviewed this aspect closely. is not exhaustive but provides working in tobacco control and a a brief overview of the more ■ How did countries react to narrative review of the literature on prominent activities conducted the emerging evidence on the COVID-19 and tobacco. Databases by the industry.
1 Parties report on the implementation of the WHO Framework Convention on Tobacco Control according to Article 21. The objective of reporting is to enable Parties to learn from each other’s experience in implementing the WHO FCTC. Parties’ reports are also the basis for review by the COP of the implementation of the WHO FCTC. Parties submit their initial report 2 years after entry into force of the WHO FCTC for that Party, and then every subsequent 3 years, through the reporting instrument adopted by COP. Since 2012, all Parties report at the same time, once every 2 years. For more information please refer to https://www.who.int/fctc/reporting/en/.
2 United Nations Department of Economic and Social Affairs, Population Division in World population prospects: the revision (median fertility projection for the year 2020). For more information please refer to https://population.un.org/wpp/Download/Standard/Population/.
3 The World Bank: World development indicators published July 1, 2020. For more information please refer to https://datahelpdesk.worldbank.org/ knowledgebase/.
4 “Complete” is used in this report to mean that smoking is not permitted, with no exemptions allowed, except in residences and indoor places that serve as equivalents to long-term residential facilities, such as prisons and long-term health and social care facilities such as psychiatric units and nursing homes. Ventilation and any form of designated smoking rooms and/or areas do not protect from the harms of second-hand tobacco smoke, and the only laws that provide protection are those that result in the complete absence of smoking in all public places
5 When legislation did not explicitly ban the identification of non-tobacco products with tobacco brand names (brand stretching) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand stretching was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply.
6 When legislation did not explicitly ban the use of brand names of non-tobacco products for tobacco products (brand sharing) and did not provide a definition of tobacco advertising and promotion, it was interpreted that brand sharing was covered by the existing ban of all forms of advertising and promotion when the country was a Party to the WHO FCTC, assuming that the WHO FCTC definitions apply.
7 Designated smoking room exceptions in the legislation that include at least three out of the six following characteristics, and include at least criteria 5 or 6, are denoted in the annex tables with an asterisk. The designated smoking room must: ■ be a closed indoor environment; ■ be furnished with automatic doors, generally kept closed; ■ be non-transit premises for non-smokers; ■ be furnished with appropriate forced- ventilation mechanical devices; ■ have appropriate installations and functional openings installed, and air must be expelled from the premises; ■ be maintained, with reference to surrounding areas, in a depression not lower than 5 Pascals.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 127 TECHNICAL NOTE II TOBACCO USE PREVALENCE IN WHO MEMBER STATES
Monitoring the prevalence of tobacco (DHS) and the Multiple Indicator is published alongside this report at use is central to efforts to control the Cluster Survey (MICS); and https://www.who.int/health-topics/ global tobacco epidemic. Reliable tobacco/. ■ an extensive search through WHO prevalence data on the magnitude of regional offices and WHO country the tobacco epidemic and its influencing offices to identify country-specific factors provide the information needed surveys not part of international Analysis and presentation to plan, adopt and evaluate the impact surveillance systems – such as the of tobacco control interventions. This of tobacco use prevalence National Survey of Risk Factors in report contains survey data for both Argentina, or the Mauritius Non indicators smoking1 and smokeless tobacco use Communicable Diseases Survey. among young people and adults Estimation method (Annex XI). It also presents WHO- For the analysis, information from surveys A statistical model based on a Bayesian modelled, age-standardized prevalence conducted since 1990 was used if it: negative binomial meta-regression estimates for tobacco use for people ■ was officially recognized by the was used to model crude adjusted aged 15 years and over (Annex X). This national health authority; and age-standardized estimates for technical note provides information on countries for each indicator (current the method used to generate the WHO ■ included randomly selected and daily tobacco use, current and daily prevalence estimates. participants who were representative tobacco smoking, and current and daily of the general population; cigarette smoking) separately for men ■ provided data for one or more of and women. A trend was considered to Sources of information six tobacco use definitions: daily be statistically significant if the posterior tobacco user, current tobacco user, probability of the increase or decrease For the analysis, the following sources of daily tobacco smoker, current tobacco was greater than 0.75. A full description information were explored (where official smoker, daily cigarette smoker or of the method is available as a peer- survey reports explaining the sampling, current cigarette smoker; and reviewed article in the Lancet, volume methodology and detailed results were 385, No. 9972, p966–976 (2015). ■ presented prevalence values by age not publicly available, Member States and sex. Once the prevalence rates from national were asked to provide them): surveys were compiled into a dataset, the The above indicators provide for the ■ information on surveys provided model was fit to calculate trend estimates most complete representation of by Parties to the WHO FCTC for the six indicators specified above. tobacco use across countries and at the Secretariat; same time help minimize attrition of The model has two main components: ■ information collected through WHO countries from further analysis because (a) adjusting for missing indicators tobacco-focused surveys conducted of lack of adequate data. Although and age groups, and (b) running the under the aegis of the Global differences exist in the types of tobacco regression to generate an estimate of Tobacco Surveillance System – in products used in different countries trends over time as well as the credible particular, the Global Adult Tobacco and grown or manufactured in different interval around the estimate. Survey (GATS); regions of the world, data on at least one of these six indicators are available Depending on the completeness of ■ tobacco information collected in most countries, thereby permitting survey data from a particular country, through other WHO surveys robust statistical analyses.2 the model at times makes use of data including WHO STEPwise surveys from other countries to fill information and World Health Surveys; The information identified above is gaps. Countries with data gaps “borrow stored in the WHO Tobacco Control ■ other systems-based surveys information” from “priors” calculated Global DataBank and, along with the undertaken by other organizations, from their data pooled with data from source code used for generating the 3 including surveys such as the countries in the same UN subregion. WHO smoking prevalence estimates, Demographic and Health Surveys
128 | WORLD HEALTH ORGANIZATION Differences in age groups more borrowed information blended into the age-specific rates by sex in each covered by each survey their trend line than countries with many population to one standard population Survey results for any one country were surveys. To allow global comparability, (this report uses the WHO Standard sometimes reported for a variety of the trend calculation is the same for all Population, a fictitious population whose different age groups. Where data were countries. No allowances are made for age distribution is largely reflective of missing for any age group in the range inflection points in the specific years the population age structure of low- of 15 years and above, the model uses when tobacco control policies were and middle-income countries). The available data from a country’s other introduced or improved. Therefore, WHO resulting age-standardized rates refer to surveys to estimate the age pattern of estimates and projections may differ from the number of smokers per 100 WHO tobacco use. For ages that the country countries’ own estimates and projections. Standard Population. As a result, the rates generated using this process are only has never surveyed, the average age For this report, country-level trends have hypothetical numbers with no inherent pattern seen in countries in the same UN been summarized into average trends for meaning. They are only meaningful subregion is applied to the country’s data. high-income countries, middle-income when comparing rates obtained from countries, low-income countries and one country with those obtained in Differences in the indicators a global average. Trends from 2007 to another country. of tobacco use measured 2019 are presented. Similarly, countries may report different indicators across surveys (e.g. current In this report, comparable estimates of current tobacco use among people smoking in one survey and daily smoking Comparison with smoking in another, or tobacco smoking in one aged 15 years and over are presented and cigarette smoking in another). Where at country-level for the year 2019. estimates in earlier editions data were missing for any indicator, The rates are comparable because the of this report the model uses available data from a model has standardized the survey The estimates in this report are country’s other surveys to estimate the results as described above, and then consistent with each other but not with missing information. For indicators on age-standardized as described below. estimates produced for earlier editions which the country has never reported, When calculating global and World of this report. While the method of the average relationships seen in Bank income group average prevalence estimation is the same, the updated countries in the same UN subregion are rates, countries without estimates were data set for the period 1990–2020 is applied to the country’s data. included in the averages by assuming much more complete. their prevalence rates are the average Modelled results rates seen in the UN subregion to For example, since the WHO report on The model was run for all countries with which they belong.3 the global tobacco epidemic, 2019, 243 surveys that met the inclusion criteria. national surveys from 100 countries Results for countries with insufficient Age-standardized have been added to the data set, and survey data (e.g. only one survey with a prevalence rates 40 existing surveys have been updated detailed age breakdown for prevalence Comparison of crude rates between two with additional data points. Each round for either sex) were not reported. or more countries at one point in time, or of WHO estimates is calculated using all available survey data back to 1990. The The output of the model is a set of trend of one country at different points in time, more data points available, the more lines for each country that summarize its can be misleading if the two populations robust the trend estimates are. Each prevalence history from 2000 to the year being compared have significantly estimation round therefore improves of the most recent survey. If the most different age distributions or differences upon earlier published estimates, and recent survey was earlier than 2019, the in tobacco use by sex. The method of only the latest round should be used. trend is projected to 2019. The projection age-standardization is commonly used While country-level estimates in this assumes that the pace and level of to overcome this problem and allows for report pertain only to 2019, the trend adoption of new policies during the meaningful comparison of prevalence from 2000 to 2025 is published in the period covered by the countries’ national between countries, once all other biennial WHO global report on trends surveys continued unchanged to 2019. comparison issues described have been in tobacco smoking 2000–2025. Countries with few surveys will have addressed. The method involves applying
1 Tobacco smoking includes cigarette, cigar, pipe, hookah, shisha, water-pipe, heated tobacco products and any other form of smoked tobacco. 2 For countries where prevalence of smokeless tobacco use is reported, we have published these data. 3 For a complete list of countries by UN subregion, please refer to pages ix to xiii of World population prospects: the 2019 revision, published by the UN Department of Economic and Social Affairs at https://population.un.org/wpp/Download/Standard/Population/ (accessed December 17, 2020). Please note that, for the purposes of tobacco use analysis, the following adjustments were made: (i) Eastern Africa subregion was divided into two regions: Eastern African Islands and Remainder of Eastern Africa; (ii) Armenia, Azerbaijan, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Tajikistan, Uzbekistan and Turkmenistan were classified with Eastern Europe; (iii) Cyprus, Israel and Turkey were classified with Southern Europe; (iv) Central Africa and Southern Africa were combined into one subregion; (v) Melanesia, Micronesia and Polynesia subregions were combined into one subregion; and (vi) Ireland and the United Kingdom were combined with Northern America. WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 129 TECHNICAL NOTE III TOBACCO TAXES IN WHO MEMBER STATES
This report includes appendices The tax data collected focus on indirect containing information on the 1. Data collection taxes levied on tobacco products (e.g. share of total and excise taxes in excise taxes of various types, import All data were collected between June the price of the most widely sold duties, value added taxes), which 2020 and February 2021 by WHO brand of cigarettes, based on tax usually have the most significant impact regional data collectors. The two main policy information collected from on the price of tobacco products. inputs into calculating the share of total each country. This note contains Within indirect taxes, excise taxes are and excise taxes were (1) prices and information on the methodology used the most important because they are (2) tax rates and structure. Prices were by WHO to estimate the share of applied exclusively to tobacco and collected for the most widely sold brand total and tobacco excise taxes in the contribute the most to increasing of cigarettes, the least-expensive brand price of a pack of 20 cigarettes using the price of tobacco products and and a premium brand for July 2020. country-reported data. It also provides subsequently reducing consumption. information on other data collected Data on tax structure were collected Thus, rates, amounts and point of for this report in relation to tobacco through contacts with ministries of application of excise taxes are central taxation and price and tax data on finance. The validity of this information components of the data collected. heated tobacco products and nicotine was checked against other sources. For Certain other taxes, in particular and non-nicotine delivery systems. many countries, this was done through direct taxes such as corporate taxes, the wealth of work and knowledge can potentially impact tobacco accumulated by WHO working directly prices to the extent that producers with ministries of finance on tobacco pass them on to final consumers. taxation since 2009. Other sources, However, because of the practical including tax law documents, decrees difficulty of obtaining information and official schedules of tax rates and on these taxes and the complexity in structures and trade information, when estimating their potential impact on available, were either provided by data price in a consistent manner across collectors or were downloaded from countries, they are not considered. ministerial websites.
130 | WORLD HEALTH ORGANIZATION The table below describes the types of tax information collected.
1. Specific excise A specific excise tax is a tax on a selected good produced for sale within a country or taxes imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of an amount per stick, pack, per 1000 sticks, or per kilogram. Example: US$ 1.50 per pack of 20 cigarettes.
2. Ad valorem An ad valorem excise tax is a tax on a selected good produced for sale within a excise taxes country or imported and sold in that country. In general, the tax is collected from the manufacturer or at the point of entry into the country by the importer, in addition to import duties. These taxes come in the form of a percentage of the value of a transaction between two independent entities at some point of the production/ distribution chain; ad valorem taxes are generally applied to the value of the transactions between the manufacturer and the retailer/wholesaler. Example: 60% of the manufacturer’s price.
3. Import duties An import duty is a tax on a selected good imported into a country to be consumed in that country (i.e. the goods are not in transit to another country). In general, import duties are collected from the importer at the point of entry into the country. These taxes can be either specific or ad valorem. Specific import duties are applied in the same way as specific excise taxes (e.g. an amount per 1000 sticks). Ad valorem import duties are generally applied to the CIF (cost, insurance, freight) value, i.e. the value of the unloaded consignment that includes the cost of the product itself, insurance and transport and unloading. Example: 50% import duty levied on CIF.
4. Value added taxes The value-added tax (VAT) is a “multi-stage” tax on all consumer goods and services and sales taxes applied proportionally to the price taxes the consumer pays for a product. Although manufacturers and wholesalers also participate in the administration and payment of the tax all along the manufacturing/distribution chain, they are all reimbursed through a tax credit system, so that the only entity who pays in the end is the final consumer. Most countries that impose a VAT do so on a base that includes any excise tax and customs duty. Example: VAT representing 10% of the retail price.
Some countries, however, impose sales taxes instead. Unlike VAT, sales taxes are generally levied at the point of retail on the total value of goods and services purchased. For the purposes of the report, care was taken to ensure the VAT and/or sales tax shares were computed in accordance with country-specific rules.
5. Other taxes Information was also collected on any other tax that is not called an excise tax, import duty, VAT or sales tax, but that applies to either the quantity of tobacco or to the value of a transaction of a tobacco product, with as much detail as possible regarding what is taxed and how the base is defined.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 131 The import duty was only used in the A similar methodology was used to 2. Data analysis calculation of tax shares if the most calculate the price and tax share of the sold brand of cigarettes was imported most common type of smoked (other The price of the most sold brand into the country. Import duty was than cigarettes) and smokeless tobacco of cigarettes was considered in the not applied in total tax calculation for products, as reported by each country. calculation of the tax as a share of the countries reporting that the most sold The calculation was made for the retail price reported in Annex table brand, even if an international brand, price of a product for 20 grams of any 9.1 in online Annex IX. In the case was produced locally. In cases where smoked or smokeless tobacco product, of countries where different levels the imported cigarettes originated from 20 sticks of cigarettes, bidis and heated of taxes are applied on cigarettes a country with which a bilateral or tobacco products (HTPs) and one stick based on length of cigarette, quantity multilateral trade agreement waived the of cigars and cigarillos. For the e-liquid produced, or type (e.g. filter vs. duty, care was taken to ensure that the of closed electronic nicotine or non- non-filter), only the relevant rate import duty was not taken into account nicotine delivery systems (ENDS/ENNDS) that applied to the most sold brand in calculating taxes levied. the price and tax was calculated for was used in the calculation. 1 ml while for open systems, it was “Other taxes” are all other indirect In the case of Canada and the United calculated for 10 ml. Price and tax for taxes not reported as excise taxes, States, national average estimates smoked tobacco products (including import duties or VAT. An example of calculated for prices and taxes reflect bidis, cigarillos, cigars, pipe tobacco, such tax is the environmental levy. the fact that different rates are applied roll-your-own or waterpipe tobacco) by state/province over and above the The next step of the exercise was to was calculated for 69 countries, while applicable federal tax. In the case convert all taxes to the same base – in the calculation for smokeless tobacco of Brazil, where state VATs vary, the our case, the tax- inclusive retail sale price products (chewing tobacco, dry snuff, highest rate, which is applied in most (hereafter referred to as P). Standardizing moist snuff or nose tobacco ) was States, was applied. In the Federated bases is important in calculating tax share made for 21 countries. Price and tax States of Micronesia, which also has correctly, as the example in the table was also calculated for HTPs for 51 varying VAT rates across states, the VAT shows. Country B apparently applies countries, for the e-liquid of closed rate applicable to the state where price the same ad valorem tax rate (20%) as ENDS/ENNDS for 45 countries and for data was collected (Pohnpei) was used. Country A, but in fact ends up with a the e-liquid of open ENDS/ENNDS for A weighted average of retail price and higher tax rate and a higher final price 52 countries (see tables 9.3 and 9.7 in tax were calculated for China given the because the tax is applied later in the online Annex IX). very large array of brands sold in the distribution chain. Comparing reported market: the most sold brand changing statutory ad valorem tax rates without almost every year and representing a taking into account the stage at which very small share of the market was not the tax is applied could therefore lead representative. to biased results.
Country A Country B (US$) (US$)
[A] Manufacturer’s price (same in both countries) 2.00 2.00
[B] Country A: 0.40 - ad valorem tax on manufacturer’s price (20%) = 20% x [A]
[C] Retailer’s and wholesaler’s profit margin (same in both countries) 0.20 0.20
[D] Country B: ad valorem tax on retailer’s price (20%) = 20% x [E] - 0.55
[E] Final price = P = [A]+[B]+[C] or [A]+[C]+[D] 2.60 2.75
Total tax share (as % of P) 0.40/2.60 = 15.4% 0.55/2.75 = 20%
132 | WORLD HEALTH ORGANIZATION Where: Using equation (2), it is possible to 3. Calculation recover M: P = Price per pack of 20 cigarettes As an example of the calculations of the most popular brand P π – – Tas consumed locally; 1 + VAT% performed, denote Sts as the share of M = 3 (1 + Tav%) x (1 + ID) taxes in the price of a widely consumed M = Manufacturer’s/distributor’s brand of cigarettes (20-cigarette pack price, or import price if the π, or wholesalers’ and retailers’ profit or equivalent). Then, brand is imported; margins, are rarely publicly disclosed and will vary from country to country. S = S + S + S + S ts as av id VAT 1 ID = Import duty rate (where For domestically produced most Where: applicable) on a pack of 20 popular brands, we considered π to cigarettes;1 Sts = Total share of taxes in the price be nil (i.e. =0) in the calculation of M
of a pack of cigarettes; Tav = Statutory rate of ad valorem tax; because the retailer’s and wholesaler’s margins are assumed to be small. S = Share of amount-specific excise T = Amount-specific excise tax on as as Setting the margin to 0, however, taxes in the price of a pack of a pack of 20 cigarettes; would result in an overestimation of cigarettes; π = Retailer’s, wholesaler’s and M and therefore of the base for the importer’s profit per pack Sav = Share of ad valorem excise ad valorem tax. This will in turn result taxes in the price of a pack of 20 cigarettes (sometimes in an overestimation of the amount of of cigarettes; expressed as a mark-up); ad valorem tax. Since the goal of this exercise is to measure how high the S = Share of import duties in the price VAT = Statutory rate of value added id share of tobacco taxes is in the price of of a pack of cigarettes (if the most tax on VAT-exclusive price. a typical pack of cigarettes, assuming popular brand is imported); Changes to this formula were made that the retailer’s/wholesaler’s profit based on country-specific considerations SVAT = Share of the value added tax in (π) is nil, therefore, does not penalize the price of a pack of cigarettes. such as the base for the ad valorem countries by underestimating their ad tax and excise tax, the existence – or Calculating S is straightforward valorem taxes. Considering this, it was as not – of ad valorem and specific excise and involves dividing the specific tax decided that unless country-specific taxes, and whether the most popular amount for a 20-cigarette pack by information was made available to brand was locally produced or imported. the total price. Unlike S , the share WHO, the retailer’s or wholesaler’s as In many cases (particularly in low- and of ad valorem taxes, S , depending margin would be assumed to be nil for av middle-income countries) the base on the base it is applied on, can domestically produced brands. for ad valorem excise tax was the be much more difficult to calculate manufacturer’s price or CIF value. But in For countries where the most popular and would involve making some fact, the base of the ad valorem varies brand is imported, the import duty assumptions described below. Import a lot around the world and can include is applied on CIF values, and the duties are sometimes amount-specific, other bases, such as retail price, retail consequent excise taxes are typically sometimes value-based. S is therefore id price net of some taxes (and/or some applied on a base that includes the calculated the same way as S if it is as predefined margins), retail price net of CIF value and the import duty, but not amount-specific and the same way all taxes, etc. the importer’s profit. For domestically as Sav if it is value-based. VAT rates produced cigarettes, the producer’s reported for countries are usually Given knowledge of price (P) and price includes its own profit, so amount-specific excise tax (T ), the applied on the VAT-exclusive retail as it is automatically included in M. share S is easy to recover (=T /P). sale price but are also sometimes as as However, the importer’s profit can be The case of ad valorem taxes reported on VAT-inclusive prices. SVAT relatively significant and setting it to (and, where applicable, S ) is fairly is calculated to consistently reflect id zero (as in the case of domestically the share of the VAT in VAT-inclusive straightforward when, by law, the manufactured cigarettes) would retail sale price. base is retail price. The calculation substantially overestimate M, and is more complicated when the base The price of a pack of cigarettes can thereby substantially overestimate is the manufacturer’s price (M) and be expressed as the following: the share of ad valorem tax in final needs to be recovered to calculate the price. For this reason, M had to be P = [(M + M × ID) + (M + M×ID) × amount of ad valorem tax. In most of estimated differently for imported T % + T + ] × (1 + VAT%), or the cases, M was not known (unless av as π products: M* (or the CIF value) was specifically reported by the country), calculated either based on information P = [M × (1 × ID) × (1 + Tav%) + Tas + π] and therefore had to be estimated. reported by countries or using × (1 + VAT%) 2 secondary sources (data from the United Nations Comtrade database2).
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 133 M* was normally calculated as the Republic of the Congo, New Zealand8, import price of cigarettes in a country 4. Prices Panama, Peru, Portugal, Saint Vincent (value of cigarette imports divided by and the Grenadines (cheaper brand Primary collection of price data in this the quantity of cigarette imports for category), Angola, Ecuador, Iran and previous reports involved surveying the importing country).3 However, (Islamic Republic of), Philippines, Sierra retail outlets. Price data were collected in exceptional cases where no such Leone, Yemen (more expensive brand from two different types of outlets. data were available (Angola, Bhutan, category). In four other countries Equatorial Guinea and Libya), the Questionnaires sent to data collectors (Equatorial Guinea, Hungary, Iceland export price was considered instead. were pre-populated with the names and India) the brand reported in 2020 The ad valorem and other taxes were of the highest selling brand in each was a variant of the brand reported in then calculated in the same way as for country. The popular brand was 2018, with similar price levels and these local cigarettes, using M* rather than identified using data collected from the were treated as identical in both years M as the base, where applicable. 2018 questionnaires, through reports for purposes of price comparisons. from data collectors in 2020 and In the case of VAT, in most of the As in 2012, 2014, 2016 and 2018, the through WHO’s close collaboration with cases the base was P excluding the price used for each of the 27 countries ministries of finance. For the countries VAT (or, similarly, the manufacturer’s/ of the European Union (EU) was the where such data were not available, distributor’s price plus all excise taxes). most sold brand collected by WHO. data collectors were asked to indicate Prior to 2012, price and tax information In other words: the names of the popular brands and were taken entirely from the EU’s provide their prices. SVAT = VAT% × (1 - SVAT), equivalent to Taxation and Customs Union website. S = VAT% ÷ (1+ VAT%)(4) The two types of retail outlets were The price used by the EU in the past VAT defined as follows: to calculate tax rates was the most In some cases, however, we were popular price category (MPPC), which ■ Supermarket/hypermarket: chain informed that the VAT was not was assumed to be similar to the most or independent retail outlets effectively collected at all levels of the sold brand price category collected in with a selling space of over 2500 supply chain and was mainly levied at this report. However, since 2011, the square metres and a primary the importing or manufacturing gate. EU calculates and reports tax rates focus on selling food/beverages/ In this case, the VAT was calculated on based on the Weighted Average Price tobacco and other groceries. the basis of M (or M*) and the different (WAP) and therefore information on Hypermarkets also sell a range taxes collected at this stage, mainly the MPPC is no longer readily available of non-grocery merchandise. import duties and excise taxes (Angola, for EU countries. Consequently, in Benin, Cabo Verde, Equatorial Guinea, ■ Kiosk/newsagent/tobacconist/ order to be consistent with past years’ Gabon, Gambia, Guinea, Kiribati, independent food store: small estimates and to ensure comparability Malaysia, Mali, Mauritania, Tonga, convenience stores, retail outlets with other countries, WHO decided in Uganda and Vanuatu). selling predominantly food, 2012 to collect first hand prices of the beverages and tobacco or a 9 In sum, tax rates are calculated using most sold brand to calculate tax rates. combination of these (e.g. kiosk, the formula: The most sold brand is determined newsagent or tobacconist) or a wide based on brand market shares reported S = S + S + S + S (5) ts id as av VAT range of predominantly grocery from secondary sources, which is products (independent food stores then validated by countries. It is also Sas = Tas ÷ P or independent small grocers). worth noting that the EU tables use S = (T % × M) ÷ P or av av a WAP calculated from market data (T % × M*× (1+ S )) ÷ P 4 Most sold brands have been used av id derived from the previous year (due if the most popular brand was consistently over time to gain a better to availability of data), which means imported reflection of the change in prices. that it would not reflect a price change However, in some cases where the S = (T % × M*) ÷ P (if the import that may have occurred following a tax id ID market share of the brand initially increase in the next year. It also means duty is value-based) or used was considered to have changed that the estimated tax share may not be ID ÷ P (if import duty is a substantially, a change was made to representative of the actual tax share specific amount per pack) the new, more prevalent brand. In since the WAP and the tax rates are 2020, changes in the brand were made SVAT = VAT% ÷ (1+ VAT%) from different years. Excise and VAT for Benin, Brazil,5 Cambodia, Japan,6 rates are still collected from the EU Madagascar, Micronesia (Federated published tables. However, tax shares, States of),7 Venezuela (Bolivarian as computed and presented in this Republic of) (different brand but same report, will not necessarily be similar price category), Chad, Democratic
134 | WORLD HEALTH ORGANIZATION to the rates published by the EU. This (e.g. Andorra, Austria, Belize, Brazil, Yemen and the Philippines). In the is mainly due to the calculation of the Bulgaria, Burundi, Dominica, Ecuador, case of Ecuador the tax proportion specific excise tax rates as a percentage El Salvador, Germany, Greece, decreased despite no tax change, of the retail price, which will vary Malaysia, Mauritius, Micronesia because of the apparent increase depending on the price used. The most (Federated States of), Palau, Sao Tome in prices due to the new, more sold brand was used for all EU countries and Principe, Switzerland, Tunisia, expensive brand reported as the except for Finland, who reported to Uganda, United Republic of Tanzania). most sold brand. WHO its weighted average price (WAP) ■ In other cases, prices increased Finally, when new, improved information for 2008, 2010, 2012, 2014, 2016, 2018 above tax increases, leading to was provided in terms of taxation and and 2020. a decrease in tax share for a prices for some countries, corrections specific or mixed excise structure were made in the calculations of tax (e.g. Australia, Belgium, Bolivia rates for 2008, 2010, 2012, 2014, 2016, 5. Considerations in (Plurinational State of), Canada, and 2018 estimates, as needed. interpreting tax share Chile, Colombia, Costa Rica, Dominican Republic, Fiji, Iceland, changes Japan, Jordan, Kenya, Latvia, 6. Taxation of novel and Lesotho, Luxembourg, Mongolia, Changes in tax as a share of price are emerging nicotine and not only dependent on tax changes Namibia, Nepal, New Zealand, but also on price changes. Therefore, North Macedonia, Norway, Papua tobacco products despite an increase in tax, the tax share New Guinea, Russian Federation, (see Table 9.3 for HTPs Samoa, Serbia, Seychelles, Slovakia, could remain the same or go down; and 9.7 for ENDS/ENNDS, similarly, sometimes a tax share can Slovenia, South Africa, Sweden, increase even if there is no change/ Tajikistan, Ukraine, the United online Annex IX) increase in the tax. Kingdom, Uruguay, Zambia, Zimbabwe). Heated tobacco products (HTPs) In the current database, there are cases ■ Similar to cigarettes, the price of the where taxes increased between 2018 In the case of imported products, most sold brand of sticks (not the and 2020 but the share of tax as a the CIF value is an external variable devices) has been collected and where percentage of the price went down. that also influences the calculation applicable, taxes applied. The same This is mainly due to the fact that, of tax share. This has implications methodology used for calculating in absolute terms, the price increase in countries where ad valorem the tax of cigarettes was followed for was larger than the tax increase is based on the CIF value, when HTPs. Only two notable differences (particularly in the case of specific import duties are applicable on were applied: when specific excise tax excise tax increases). For example, in the CIF value or when the VAT is was applied on the weight of tobacco Kenya, the specific excise tax increased calculated on the base of CIF value contained in the sticks, the assumption from 2500 KES per 1000 cigarettes in + excise rather than VAT exclusive was made that each stick contained 2018 to 3,157 KES per 1000 cigarettes retail price. For example, if the CIF 0.3 grams of tobacco (or 6 grams in 2020 (a 26.3% increase), while the value increases, the base for the per pack of 20). This assumption was price of the most sold brand increased application of the tax is higher, made based on an average estimate from 130 to 250 KES per pack (a 92% leading to a higher tax percentage published by the e-cigarettes market increase). In terms of tax share the if nothing else changes. Countries data provider ECigIntelligence10. The excise represented 38.5% of the price that have seen changes in their second assumption was made on the in 2018 and it went down to 25.3% of tax share mainly due to changes value of the CIF for countries that the price in 2020. This is because prices in CIF value include Gabon, applied a tax based on the CIF value. rose more than taxes. Ghana, Niger, and Vanuatu. Given the lack available data on the Care should also be taken in relation In the same way, there are cases where import value of HTPs, an extrapolation to countries where the most sold increases (decreases) in tax as a share was made assuming the CIF value of brand changed between 2018 of price were mitigated by factors HTPs would be about double the CIF and 2020. This also has had an not directly related to tax rates. In the value of cigarettes. This was based on impact on the tax proportion of current database, this was attributable the assumption that the cost of HTP the affected countries which had a to one or more of the following reasons: production was higher than cigarettes specific or mixed excise structure. production. Estimates of the CIF value ■ In some instances, the price increased In some cases, because the new as a proportion of retail price of the without a tax change, leading to brand reported was more expensive most sold brand of cigarette in 2018 a decrease in the tax share for a and despite tax increases, the and 2020 ranged from 10–15%. Based specific or mixed excise structure total tax share decreased (Angola,
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 135 on this, a standard CIF value of 20% ■ Whether a country applies a specific of the retail price of the most sold 7. Supplementary tax excise or a mixed system relying more brand of HTPs was applied for countries information (see Table 9.5, on the specific tax component (>50% where a CIF value was needed to online Annex IX) of total excise is specific): specific calculate the tax burden of HTPs. excises typically lead to higher prices An important consideration highlighted and a smaller price gap between Electronic nicotine and in this report is that many aspects of different brands, which is better (not non-nicotine delivery systems tobacco taxation need to be taken applicable in countries where only ad (ENDS/ENNDS) into account in order to assess if a valorem excise is applicable or where Given the heterogeneity of the ENDS/ tax policy is well designed. Tax as a no excise tax is implemented). proportion of price does not tell the ENNDS market and the difficulty in ■ If the excise applied is ad valorem or identifying a most sold brand that is whole story about the effectiveness of a if it is mixed, and whether there is a representative enough of the market tax policy. To explore other dimensions minimum specific tax. A minimum tax in a given country, data were collected of tax policy, since 2015 the report has provides protection against products on the price of the cheapest brand been collecting additional information being undervalued. It also forces available for a nicotine or non-nicotine on tobacco (cigarette) taxation and prices up since the price will not be containing e-liquid (whichever was the compiles it into data that can inform lower than the tax paid (this category cheapest available). Data were also researchers and policy-makers further does not apply to countries where collected for two types of e-liquids, on tax policy in different countries. only specific excise tax is applicable or those used for open systems and The information is compiled and where no excise tax is implemented). 11 those for closed systems. The tax was classified in this report according to ■ Base of the ad valorem tax in calculated in the same manner as for two main themes: tax structure/level countries that apply an ad valorem cigarettes with a notable difference and tax administration. Information was or a mixed excise system. Ad being the base quantity. For e-liquid, also collected in relation to countries valorem taxes applied to the retail the base reported is in volume, per ml. that earmark tobacco taxes to fund price or the retail price excluding Because of differences in prices and health programmes and/or tobacco VAT are administratively simpler. packaging, the price was standardized control activities. The different sets of The retail price is easier to determine per 10 ml for open systems e-liquids data/indicators reported under each than producer price or CIF value, and per 1 ml for closed systems of the themes were developed and are and therefore there is less risk of e-liquids. Similar to the case of HTPs justified based on evidence provided undervaluation (not applicable in and where a CIF value was needed in past reports. countries where only specific excise to calculate the tax burden on ENDS/ is applicable, or where no excise tax ENNDS e-liquids, given the lack of data, Tax structure/level is implemented). assumptions were made regarding the ■ Excise tax proportion of price: CIF value as a proportion of the retail ■ If the excise tax applied is specific higher tax rates and greater reliance price of the cheapest brand reported. or if it is mixed, and whether on excise is better. Assuming the CIF value was a proxy for the specific tax component is the cost of production and, based on ■ Type of excise applied: if excise tax automatically adjusted for inflation information from ECigIntelligence that is specific, ad valorem, a mix of the (or other). If the specific tax is not mark-ups at the wholesale and retail two, or if no excise is applied. adjusted for inflation (or another levels could represent up to 100% of ■ Uniform vs. tiered excise tax indicator such as income) over time, the cost at each level, it was assumed system: a uniform excise is easier its impact will be eroded. It is good that the CIF value would be a bit less to administer than a tiered system to have it adjusted automatically than a third of the price, at around where variable rates apply based (this category does not apply to 20% of the final retail price. A base of on selected criteria within one countries where only ad valorem 20% of the retail price was assigned tobacco product (not applicable excise tax is applicable or where no for countries where the ad valorem in countries where no excise tax excise tax is implemented). excise or import duty was calculated is implemented). ■ Price dispersion: share of cheapest on CIF value (except for Morocco and brand price in premium brand price Peru where a CIF value was reported by (cheapest brand price ÷ premium national authorities). brand price × 100). The higher the proportion, the smaller the gap and the fewer are the opportunities for substitution to cheaper brands.
136 | WORLD HEALTH ORGANIZATION Tax administration Republic of)). For each country–year 8. Estimates of the Sales of duty free cigarettes: In most pair, the currency reported for the countries tobacco products are found affordability of cigarettes most sold brand was tallied with the to be sold without excise (and other (see Table 9.6, online corresponding currency for the GDP series, and exchange rate conversions indirect taxes such as VAT and import Annex IX) duties) in duty-free shops in airports, on and adjustments were performed as needed (Belarus, Cambodia, Estonia, international transport vehicles and/or The affordability of cigarettes for each Mauritania, Latvia, Liberia, Lithuania, Sao other tax-free shops. Duty-free tobacco of the years 2010, 2012, 2014, 2016, Tome and Principe, Venezuela (Bolivarian products are usually made available to 2018 and 2020 was measured by the Republic of), Zambia, Zimbabwe). travellers going out of the country, but per capita GDP required to purchase they are now also made available for 2000 cigarettes of the most sold To assess whether affordability travellers entering a country. Banning brand reported in that year. Analysis changed on average since 2010, the the sale of duty-free cigarettes for of affordability in this report informs average annual percentage change in personal consumption reduces the the following: affordability was calculated as the least chance that these products end up in squares growth rate for all countries ■ Affordability index (% of GDP per the illicit market. Additionally, there with 4 or more years of data. This capita to buy 2000 cigarettes): across is no justification for selling a deadly criterion automatically excluded Bhutan, countries, a higher value indicates product duty-free; those foregone taxes Malawi and South Sudan, as less than cigarettes are relatively more are a revenue loss for the government. 4 years of price data were available for expensive in relation to income. Some countries have already acted analysis. Additionally, countries that did and have banned the sale of duty-free ■ Whether cigarettes have become not report price data for the most sold tobacco products. Those products relatively more affordable between brand in 2020 were excluded (Barbados, may still be found in airport and other 2010 and 2020 (change in the Brunei Darussalam, Central African tax-free shops, but they are sold with affordability index as measured Republic, Cook Islands, Cuba, Djibouti, (excise) taxes included. above, between 20010 and Eritrea, Grenada, Guinea-Bissau, Haiti, 2020): as affordability decreases, Saint Kitts and Nevis, San Marino, and consumption is discouraged. Earmarking (portion of taxes or Solomon Islands). revenues from taxes dedicated to Estimates of GDP per capita in local The affordability of cigarettes was health and/or tobacco control). currency units were sourced from the judged to have been unchanged if the Taxes can generate substantial IMF’s World Economic Outlook (WEO) least squares trend in the per capita GDP revenues. Earmarking all or a part of database which provides a complete required to purchase 2000 cigarettes tobacco tax revenues can be a useful series of estimates for most of the 195 (that is, 100 packs of 20 cigarettes) tool for improving the political economy countries reported on. Where GDP was not significant at the 5% level. of tobacco tax increases. Setting per capita data were not available in Cigarettes were judged to have become aside portions of tax revenue to fund the WEO database, the World Bank’s less (more) affordable on average if the tobacco control efforts or relevant GDP per capita data series was used. least squares trend in the per capita GDP health programmes can help convince Countries for which no relevant data required to purchase 2000 cigarettes the public, politicians and officials of were available in the IMF WEO database was positive (negative) and significantly the value of significant tobacco tax or World Bank’s GDP per capita series different from zero at the 5% level. increases, the ultimate goal of which were dropped from the affordability is to reduce tobacco use (see Table 9.4 analysis (Andorra, Cook Islands, Cuba, in online Annex IX). Democratic People’s Republic of Korea, Monaco, Niue, Somalia, Syrian Arab Republic and Venezuela (Bolivarian
1 Import duties may vary depending on the 4 Or Sav = (Tav % × M*) ÷ P, if the ad valorem 9 Due to a lack of capacity, the price is collected country of origin in cases of preferential trade tax was applied only on the CIF value, not the for cigarettes only while calculations for other agreements. WHO tried to determine the origin CIF value + the import duty. smoked or smokeless tobacco products are of the pack and relevance of using such rates made using the EU tables when available, where possible. 5 Brand change within the same price category including the WAP and tax rates. but price also increased compared to 2018. 2 https://comtrade.un.org/ 10 ECigIntelligence.com (restricted access). 6 Brand change within the same price category 3 When quantity was reported in weight (kg) but price also increased compared to 2018. 11 Open systems are devices that allow the user rather than number of sticks, the conversion to buy e-liquids and fill their device with the was made assuming one stick contained one 7 Brand change within the same price category mixtures they want (with no nicotine, different gram of tobacco. but price also increased compared to 2018. nicotine concentrations and/or flavours). Closed systems are products that come with a prefilled 8 Brand change to a cheaper price category but container (called a cartridge, pod or tank). price also increased compared to 2018 WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 137 138 | WORLD HEALTH ORGANIZATION ANNEX I REGIONAL SUMMARY OF MPOWER MEASURES
Annex I provides an overview of Country-level data were generally but The summary measures reported for selected tobacco control policies not always provided with supporting the WHO report on the Global Tobacco in countries. For each WHO region documents such as laws, regulations, Epidemic, 2021 are the same as those an overview table is presented that policy documents, etc. Available in the 2019 report. The methodology includes information on monitoring documents were assessed by WHO and used to calculate each indicator is and prevalence, smoke-free this Annex provides summary measures described in Technical Note I. This environments, treatment of tobacco or indicators of country achievements review, however, does not constitute a dependence, health warnings and for each of the MPOWER measures. thorough and complete legal analysis packaging, anti-tobacco mass media Detailed information, including detailed of each country’s legislation. Except campaigns, advertising, promotion footnotes on each of the indicators, for smoke-free environments and bans and sponsorship bans, taxation is available in Annex II for electronic on tobacco advertising, promotion levels, and affordability of cigarettes, nicotine delivery systems, in Annex VI and sponsorship, data were collected based on the methodology outlined for smokefree environments, health at the national/ federal level only in Technical Notes I, II and III. warnings and packaging, anti-tobacco and therefore provide incomplete mass media campaigns, advertising, information about Member States promotion and sponsorship bans, where subnational governments play and in Annex IX for tobacco taxation an active role in tobacco control. and affordability. It is important to Daily smoking prevalence for the note that data about laws reflect the population aged 15 years and over status of legislation adopted by 31 in 2019 is an indicator modelled December 2020 which has a stated by WHO from tobacco use surveys date of effect and is not undergoing published by Member States. Tobacco a legal challenge that could impact smoking is one of the most widely the date of implementation. reported indicators in country surveys. The calculation of WHO estimates to allow international comparison is described in Technical Note II.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 139 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.1 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 Africa COMPLIANCE COMPLIANCE SINCE 2010 Summary of Algeria 14% IIIII IIIIIIIIII 35.5% Yes MPOWER measures Angola . . . IIIIIIIII IIIIIIIIII 12.1% Yes Benin 4% IIIII IIIIIIIII 9.5% No Botswana 13% — IIIIIIIIII 52.2% Yes p Burkina Faso 9% IIII IIIIIII 43.5% Burundi 7% IIII 37.3% Yes Cabo Verde 6% IIIII IIIIIIII 19.5% q Cameroon 5% ...... 43.2% Central African Republic . . . — — ...... Chad 6% IIII IIIIIIIII 51.6% p Comoros 10% IIIIII IIIII 73.8% Congo 10% IIIIIIIIII 26.9% Yes q Côte d'Ivoire 9% — IIIIII 34.5% No p
Democratic Republic 9% III IIIIIII 52.1% No of the Congo q p Equatorial Guinea . . . — — 24.2% Yes q Eritrea 4% — ...... Eswatini 6% — . . . 53.5% No Ethiopia 3% IIIIIII IIIIIII 51.2% p p p p Gabon . . . III IIIIIIIIII 21.6% q Gambia 9% IIIII 8 IIIIIIIIII 48.7% Yes p Ghana 2% — IIIIIII 31.8% Guinea . . . IIIIIIIIII 37.0% Guinea-Bissau 7% — — ...... Kenya 7% — IIIIIIII 39.0% q Lesotho 18% IIIII — 50.6% Liberia 6% — — 56.8% p Madagascar 13% IIIII IIIIIIIII 80.4% Malawi 7% — — 56.3% . . . Mali 6% — IIIIII 27.7% No Mauritania 7% IIIII IIII 5.9% p p Mauritius 15% IIIIII IIIIIIIII 81.2% Yes Mozambique 11% IIIII IIIII 28.5% Yes Namibia 14% IIIII IIIII 42.0% Niger 4% IIIIIII 31.8% q p Nigeria 3% III 8 IIII 35.1% p Rwanda 9% — IIIII 64.3% Sao Tome and Principe 4% — 33.7% Senegal 5% IIIIIII IIIIIIIIII 38.2% Yes q Seychelles 15% IIIIIIIIII IIIIIIIIII 69.5% Sierra Leone 12% — — 22.6% Yes South Africa 17% — IIIIIIII 52.7% South Sudan . . . — — 66.1% . . . Togo 4% IIIIII IIIIIIIIII 41.4% Yes p Uganda 5% IIIIII IIIIIIIII 34.6% Yes United Republic of Tanzania 6% — . . . 30.0% No Zambia 10% IIII — 38.8% Zimbabwe 8% IIIII — 29.3%
140 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Algeria 14% IIIII IIIIIIIIII 35.5% Yes From 20% to 29.9% Angola . . . IIIIIIIII IIIIIIIIII 12.1% Yes Ban on national television, radio and print From 15% to 19.9% media only Benin 4% IIIII IIIIIIIII 9.5% No Less than 15% Ban on national television, radio and print Botswana 13% — IIIIIIIIII 52.2% Yes p * The figures should be used strictly for the purpose of drawing media as well as on some but not all other comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising Burkina Faso 9% IIII IIIIIII 43.5% absolute number of daily tobacco smokers in a country. Ban on all forms of direct and indirect Burundi 7% IIII 37.3% Yes MONITORING: PREVALENCE DATA advertising (or at least 90% of the population Cabo Verde 6% IIIII IIIIIIII 19.5% q covered by subnational legislation completely No known data or no recent data or data Cameroon 5% ...... 43.2% banning tobacco advertising, promotion that are not both recent and representative and sponsorship) Central African Republic . . . — — ...... Recent and representative data for either Chad 6% IIII IIIIIIIII 51.6% p adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE Recent and representative data for both OF THE MOST WIDELY SOLD BRAND OF CIGARETTES Comoros 10% IIIIII IIIII 73.8% adults and youth Data not reported Congo 10% IIIIIIIIII 26.9% Yes q Recent, representative and periodic data < 25% of retail price is tax Côte d'Ivoire 9% — IIIIII 34.5% No p for both adults and youth Democratic Republic ≥ 25% and <50% of retail price is tax 9% III IIIIIII 52.1% No q p of the Congo SMOKE-FREE ENVIRONMENTS: SMOKING BANS ≥ 50% and <75% of retail price is tax Equatorial Guinea . . . — — 24.2% Yes q Data not reported ≥ 75% of retail price is tax Eritrea 4% — ...... Complete absence of ban, or up to two public AFFORDABILITY OF CIGARETTES Eswatini 6% — . . . 53.5% No places completely smoke-free Three to five public places completely smoke-free Ethiopia 3% IIIIIII IIIIIII 51.2% p p p p Cigarettes less affordable - Trend in per capita Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since Gabon . . . III IIIIIIIIII 21.6% q 2010 at a rate over 1.45% per year All public places completely smoke-free (or Gambia 9% IIIII 8 IIIIIIIIII 48.7% Yes p at least 90% of the population covered by Cigarettes more affordable - Trend in per capita Ghana 2% — IIIIIII 31.8% complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since 2010 at a rate over 1.45% per year . . . IIIIIIIIII 37.0% Guinea CESSATION PROGRAMMES: No significant change in affordability of Guinea-Bissau 7% — — ...... TREATMENT OF TOBACCO DEPENDENCE cigarettes since 2010 Kenya 7% — IIIIIIII 39.0% q Data not reported ... Insufficient data to conduct a trend analysis Lesotho 18% IIIII — 50.6% None Liberia 6% — — 56.8% p NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO Madagascar 13% IIIII IIIIIIIII 80.4% SMOKE-FREE LAWS NRT and/or some cessation services (at least Malawi 7% — — 56.3% . . . one of which is cost-covered) |||||||||| ||||||||| Mali 6% — IIIIII 27.7% No National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| Mauritania 7% IIIII IIII 5.9% p p cessation services cost-covered ||||||| Mauritius 15% IIIIII IIIIIIIII 81.2% Yes HEALTH WARNINGS: |||||| Mozambique 11% IIIII IIIII 28.5% Yes HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) |||| Namibia 14% IIIII IIIII 42.0% Data not reported ||| 4% IIIIIII 31.8% No warnings or small warnings || Niger q p Minimal compliance (0/10 to 2/10) | Nigeria 3% III 8 IIII 35.1% p Medium size warnings missing some appropriate characteristics OR large warnings Rwanda 9% — IIIII 64.3% missing many appropriate characteristics SYMBOLS LEGEND Sao Tome and Principe 4% — 33.7% Medium size warnings with all appropriate Plain packaging is mandated. Senegal 5% IIIIIII IIIIIIIIII 38.2% Yes q characteristics OR large warnings missing some appropriate characteristics 8 Law adopted but not implemented by Seychelles 15% IIIIIIIIII IIIIIIIIII 69.5% Large warnings with all appropriate 31 December 2020. 12% — — 22.6% Yes Sierra Leone characteristics qp Change in POWER indicator group, up or down, South Africa 17% — IIIIIIII 52.7% between 2018 and 2020. Some 2018 data were revised in 2020. 2020 grouping rules were applied South Sudan . . . — — 66.1% . . . MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Togo 4% IIIIII IIIIIIIIII 41.4% Yes p Data not reported ... Data not reported/not available No national campaign conducted between Uganda 5% IIIIII IIIIIIIII 34.6% Yes – Data not required/not applicable July 2018 and June 2020 with a duration of at 6% — . . . 30.0% No United Republic of Tanzania least 3 weeks Zambia 10% IIII — 38.8% National campaign conducted with one to four Zimbabwe 8% IIIII — 29.3% appropriate characteristics National campaign conducted with five to six appropriate characteristics National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio
Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 141 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.2 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 The Americas COMPLIANCE COMPLIANCE SINCE 2010 Summary of Antigua and Barbuda . . . III IIIIIIIII 13.1% q MPOWER measures Argentina 18% IIIIIIII IIIIIIIII 76.6% Yes Bahamas 8% — IIIIIII 43.2% Yes Barbados 5% IIIIIIIIII — ...... Belize 5% — — 34.7%
Bolivia . . . III II 35.7% Yes (Plurinational State of) p Brazil 11% IIIIIIIIII IIIIII 81.5% Canada 9% IIIIIIIII IIIIIIIII 61.7% Yes Chile 19% IIIIIIIIII IIIIIIIII 80.0% Yes Colombia 5% IIIIIIII IIIIIIII 73.1% Yes q Costa Rica 5% IIIIIIIII IIIIII 53.6% Yes Cuba 13% IIII — ...... Dominica . . . — — 22.7% Dominican Republic 8% IIIII — 44.3% q Ecuador 4% IIIIIIII IIIIII 66.9% Yes El Salvador 5% IIIII IIIIIIII 46.5% Yes q Grenada . . . — — ...... q Guatemala 5% IIIII IIII 49.0% Guyana 9% IIIIII IIIIIIIII 27.5% No Haiti 5% — — ...... Honduras . . . IIIIIII IIIIIIIII 42.6% Yes Jamaica 7% IIIIII IIIIIIIII 42.6% Yes Mexico 7% IIIII IIIII 67.6% Nicaragua . . . III IIIII 69.4% p Panama 2% IIIIIIII IIIIIIIII 56.5% No Paraguay 8% — IIII 18.3% p Peru 6% IIIIII IIIIIII 67.7% Yes p Saint Kitts and Nevis . . . — — ...... Saint Lucia . . . IIIII — 51.3% p
Saint Vincent and the . . . — — 23.1% Yes Grenadines Suriname . . . IIIII IIIIIIIII 26.5% Yes q Trinidad and Tobago . . . IIIIIII IIIIIII 25.7% Yes United States of America 14% . . . 8 . . . 40.0% p Uruguay 18% IIIIIIIIII IIIIIIIII 65.9%
Venezuela . . . IIIIIIII IIIIIIII 73.4% . . . (Bolivarian Republic of) p
142 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Antigua and Barbuda . . . III IIIIIIIII 13.1% q From 20% to 29.9% Argentina 18% IIIIIIII IIIIIIIII 76.6% Yes Ban on national television, radio and print From 15% to 19.9% media only Bahamas 8% — IIIIIII 43.2% Yes Less than 15% Ban on national television, radio and print Barbados 5% IIIIIIIIII — ...... * The figures should be used strictly for the purpose of drawing media as well as on some but not all other comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising Belize 5% — — 34.7% absolute number of daily tobacco smokers in a country. Bolivia Ban on all forms of direct and indirect . . . III II 35.7% Yes p (Plurinational State of) MONITORING: PREVALENCE DATA advertising (or at least 90% of the population covered by subnational legislation completely 11% IIIIIIIIII IIIIII 81.5% Brazil No known data or no recent data or data banning tobacco advertising, promotion Canada 9% IIIIIIIII IIIIIIIII 61.7% Yes that are not both recent and representative and sponsorship) Recent and representative data for either Chile 19% IIIIIIIIII IIIIIIIII 80.0% Yes adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE Colombia 5% IIIIIIII IIIIIIII 73.1% Yes q Recent and representative data for both OF THE MOST WIDELY SOLD BRAND OF CIGARETTES adults and youth Costa Rica 5% IIIIIIIII IIIIII 53.6% Yes Data not reported Recent, representative and periodic data Cuba 13% IIII — ...... for both adults and youth < 25% of retail price is tax Dominica . . . — — 22.7% ≥ 25% and <50% of retail price is tax Dominican Republic 8% IIIII — 44.3% q SMOKE-FREE ENVIRONMENTS: SMOKING BANS ≥ 50% and <75% of retail price is tax Ecuador 4% IIIIIIII IIIIII 66.9% Yes Data not reported ≥ 75% of retail price is tax El Salvador 5% IIIII IIIIIIII 46.5% Yes q Complete absence of ban, or up to two public AFFORDABILITY OF CIGARETTES Grenada . . . — — ...... q places completely smoke-free Three to five public places completely smoke-free Guatemala 5% IIIII IIII 49.0% Cigarettes less affordable - Trend in per capita Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since Guyana 9% IIIIII IIIIIIIII 27.5% No 2010 at a rate over 1.45% per year All public places completely smoke-free (or Haiti 5% — — ...... at least 90% of the population covered by Cigarettes more affordable - Trend in per capita Honduras . . . IIIIIII IIIIIIIII 42.6% Yes complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since 2010 at a rate over 1.45% per year 7% IIIIII IIIIIIIII 42.6% Yes Jamaica CESSATION PROGRAMMES: No significant change in affordability of Mexico 7% IIIII IIIII 67.6% TREATMENT OF TOBACCO DEPENDENCE cigarettes since 2010 Nicaragua . . . III IIIII 69.4% p Data not reported ... Insufficient data to conduct a trend analysis Panama 2% IIIIIIII IIIIIIIII 56.5% No None Paraguay 8% — IIII 18.3% p NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO Peru 6% IIIIII IIIIIII 67.7% Yes p SMOKE-FREE LAWS NRT and/or some cessation services (at least Saint Kitts and Nevis . . . — — ...... one of which is cost-covered) |||||||||| ||||||||| Saint Lucia . . . IIIII — 51.3% p National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| cessation services cost-covered Saint Vincent and the . . . — — 23.1% Yes Grenadines ||||||| |||||| . . . IIIII IIIIIIIII 26.5% Yes HEALTH WARNINGS: Suriname q HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) Trinidad and Tobago . . . IIIIIII IIIIIII 25.7% Yes |||| Data not reported ||| United States of America 14% . . . 8 . . . 40.0% p No warnings or small warnings || Uruguay 18% IIIIIIIIII IIIIIIIII 65.9% Minimal compliance (0/10 to 2/10) Medium size warnings missing some | Venezuela . . . IIIIIIII IIIIIIII 73.4% . . . p appropriate characteristics OR large warnings (Bolivarian Republic of) missing many appropriate characteristics SYMBOLS LEGEND Medium size warnings with all appropriate characteristics OR large warnings missing Plain packaging is mandated. some appropriate characteristics 8 Law adopted but not implemented by Large warnings with all appropriate 31 December 2020. characteristics qp Change in POWER indicator group, up or down, between 2018 and 2020. Some 2018 data were revised in 2020. 2020 grouping rules were applied MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Data not reported ... Data not reported/not available No national campaign conducted between – Data not required/not applicable July 2018 and June 2020 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio
Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 143 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.3 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 South-East COMPLIANCE COMPLIANCE SINCE 2010 Asia Bangladesh 17% IIIIII IIIIIII 73.0% Yes Bhutan . . . IIIIIIII IIIIIIIIII 8.1% . . . Summary of Democratic People's 15% IIIIIIII — 0.0% . . . MPOWER measures Republic of Korea India 7% IIIIIIII IIIII 57.6% Yes Indonesia 33% II IIII 62.3% Maldives 19% IIIII IIIII 65.7% Yes p Myanmar 15% IIIII IIIIII 49.9% No Nepal 13% I IIIIIIIIII 27.0% q Sri Lanka 10% IIIIII IIIII 77.0% Yes p Thailand 17% IIIIII IIIIIIII 78.6% Timor-Leste 23% IIIIII IIIIIIIII 21.8%
144 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Bangladesh 17% IIIIII IIIIIII 73.0% Yes From 20% to 29.9% Bhutan . . . IIIIIIII IIIIIIIIII 8.1% . . . Ban on national television, radio and print From 15% to 19.9% media only Democratic People's 15% IIIIIIII — 0.0% . . . Less than 15% Republic of Korea Ban on national television, radio and print * The figures should be used strictly for the purpose of drawing media as well as on some but not all other 7% IIIIIIII IIIII 57.6% Yes India comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising absolute number of daily tobacco smokers in a country. Indonesia 33% II IIII 62.3% Ban on all forms of direct and indirect Maldives 19% IIIII IIIII 65.7% Yes p MONITORING: PREVALENCE DATA advertising (or at least 90% of the population covered by subnational legislation completely 15% IIIII IIIIII 49.9% No Myanmar No known data or no recent data or data banning tobacco advertising, promotion Nepal 13% I IIIIIIIIII 27.0% q that are not both recent and representative and sponsorship) Recent and representative data for either Sri Lanka 10% IIIIII IIIII 77.0% Yes p adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE Thailand 17% IIIIII IIIIIIII 78.6% Recent and representative data for both OF THE MOST WIDELY SOLD BRAND OF CIGARETTES adults and youth Timor-Leste 23% IIIIII IIIIIIIII 21.8% Data not reported Recent, representative and periodic data for both adults and youth < 25% of retail price is tax ≥ 25% and <50% of retail price is tax SMOKE-FREE ENVIRONMENTS: SMOKING BANS ≥ 50% and <75% of retail price is tax Data not reported ≥ 75% of retail price is tax Complete absence of ban, or up to two public places completely smoke-free AFFORDABILITY OF CIGARETTES Three to five public places completely smoke-free Cigarettes less affordable - Trend in per capita Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since 2010 at a rate over 1.45% per year All public places completely smoke-free (or at least 90% of the population covered by Cigarettes more affordable - Trend in per capita complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since 2010 at a rate over 1.45% per year CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE No significant change in affordability of cigarettes since 2010 Data not reported ... Insufficient data to conduct a trend analysis None NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS NRT and/or some cessation services (at least one of which is cost-covered) |||||||||| ||||||||| National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| cessation services cost-covered ||||||| HEALTH WARNINGS: |||||| HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) |||| Data not reported ||| No warnings or small warnings || Minimal compliance (0/10 to 2/10) Medium size warnings missing some | appropriate characteristics OR large warnings missing many appropriate characteristics SYMBOLS LEGEND Medium size warnings with all appropriate characteristics OR large warnings missing Plain packaging is mandated. some appropriate characteristics 8 Law adopted but not implemented by Large warnings with all appropriate 31 December 2020. characteristics qp Change in POWER indicator group, up or down, between 2018 and 2020. Some 2018 data were revised in 2020. 2020 grouping rules were applied MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Data not reported ... Data not reported/not available No national campaign conducted between – Data not required/not applicable July 2018 and June 2020 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio
Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 145 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.4 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 Europe COMPLIANCE COMPLIANCE SINCE 2010 Summary of Albania 18% ...... 66.7% Yes MPOWER measures Andorra 28% IIIIIII — 78.4% . . . Armenia 25% IIIIIIII 8 IIIIIIII 44.2% No p p Austria 21% IIIIIIIII IIIIIIIIII 74.5% Yes p p q Azerbaijan 18% ...... 49.7% Belarus 23% IIIIII IIIIIII 55.6% Yes Belgium 19% IIIIIIII IIIIIIIII 76.9% Yes Bosnia and Herzegovina 30% — IIIIIII 84.0% Yes Bulgaria 32% IIIII IIIIII 85.3% No Croatia 31% ...... 83.6% Cyprus 29% IIIIIII IIIIIIIIII 74.4% Yes Czechia 24% IIIIIIIII IIIIIIII 77.2% Yes Denmark 15% IIIIIIIII — 78.0% p Estonia 21% IIIIIIIIII IIIIIIIII 87.6% Finland 15% IIIIIIIIII IIIIIIIIII 88.2% Yes France 28% IIIIIIII IIIIIIIIII 83.2% Yes Georgia 27% IIIIIIII IIIIIIII 81.2% p Germany 18% — IIIIIIIII 63.5% Yes Greece 27% ...... 80.8% Yes Hungary 28% . . . . . . 72.7% Yes Iceland 10% IIIIIIIIII IIIIIIIIII 55.0% Ireland 18% IIIIIIIIII IIIIIIIIII 78.9% No Israel 18% . . . . . . 83.2% Yes p Italy 20% — IIIIIII 76.6% Yes Kazakhstan 16% — IIIIIII 55.7% Yes p Kyrgyzstan 22% III IIIII 52.9% Yes p Latvia 30% IIIIIIII IIIIIIIIII 79.9% Lithuania 22% III IIIIIIIIII 74.0% Luxembourg 17% ...... 68.3% Malta 19% ...... 77.6% No Monaco ...... — ...... Montenegro 27% ...... 77.5% Yes p Netherlands 17% . . . IIIIIIII 77.2% Yes p North Macedonia ...... 80.3% Norway 12% IIIIIIIIII IIIIIIIIII 61.6% Yes Poland 21% IIIIIIII IIIIII 78.4% Portugal 20% IIIIIIII IIIIIII 78.6% p Republic of Moldova 24% ...... 62.4% Yes Romania 27% IIIIIII IIIIIIII 69.6% Russian Federation 27% IIIIIIIII IIIIIIII 56.1% Yes San Marino ...... Serbia 33% III IIIIII 76.5% Yes Slovakia 24% IIIIIIIIII IIIIIIIIII 76.3% Yes Slovenia 20% . . . . . . 78.7% Spain 25% IIIIIIII IIIIIIII 78.2% Sweden 9% — IIIIIIIIII 68.1% Yes Switzerland 21% — . . . 59.6% Yes Tajikistan . . . III IIIIIIIII 41.9% Turkey 26% IIIIIII IIIIIIII 84.9% Turkmenistan 4% IIIIIIIII IIIIIIIIII 42.2% Yes Ukraine 24% IIIIIIII IIIIIIII 69.3% Yes
United Kingdom of Great 13% IIIIIIIIII IIIIIIIIII 79.3% Yes Britain and Northern Ireland Uzbekistan 9% ...... 56.3% p
146 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Albania 18% ...... 66.7% Yes From 20% to 29.9% Andorra 28% IIIIIII — 78.4% . . . Ban on national television, radio and print From 15% to 19.9% media only Armenia 25% IIIIIIII 8 IIIIIIII 44.2% No p p Less than 15% Ban on national television, radio and print Austria 21% IIIIIIIII IIIIIIIIII 74.5% Yes p p q * The figures should be used strictly for the purpose of drawing media as well as on some but not all other 18% ...... 49.7% comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising Azerbaijan absolute number of daily tobacco smokers in a country. Belarus 23% IIIIII IIIIIII 55.6% Yes Ban on all forms of direct and indirect MONITORING: PREVALENCE DATA advertising (or at least 90% of the population Belgium 19% IIIIIIII IIIIIIIII 76.9% Yes covered by subnational legislation completely Bosnia and Herzegovina 30% — IIIIIII 84.0% Yes No known data or no recent data or data banning tobacco advertising, promotion that are not both recent and representative and sponsorship) Bulgaria 32% IIIII IIIIII 85.3% No Recent and representative data for either Croatia 31% ...... 83.6% adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE OF THE MOST WIDELY SOLD BRAND OF CIGARETTES Cyprus 29% IIIIIII IIIIIIIIII 74.4% Yes Recent and representative data for both adults and youth 24% IIIIIIIII IIIIIIII 77.2% Yes Data not reported Czechia Recent, representative and periodic data Denmark 15% IIIIIIIII — 78.0% p for both adults and youth < 25% of retail price is tax Estonia 21% IIIIIIIIII IIIIIIIII 87.6% ≥ 25% and <50% of retail price is tax Finland 15% IIIIIIIIII IIIIIIIIII 88.2% Yes SMOKE-FREE ENVIRONMENTS: SMOKING BANS ≥ 50% and <75% of retail price is tax France 28% IIIIIIII IIIIIIIIII 83.2% Yes Data not reported ≥ 75% of retail price is tax Georgia 27% IIIIIIII IIIIIIII 81.2% p Complete absence of ban, or up to two public places completely smoke-free AFFORDABILITY OF CIGARETTES Germany 18% — IIIIIIIII 63.5% Yes Three to five public places completely smoke-free Cigarettes less affordable - Trend in per capita Greece 27% ...... 80.8% Yes Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since Hungary 28% . . . . . . 72.7% Yes 2010 at a rate over 1.45% per year All public places completely smoke-free (or Iceland 10% IIIIIIIIII IIIIIIIIII 55.0% at least 90% of the population covered by Cigarettes more affordable - Trend in per capita Ireland 18% IIIIIIIIII IIIIIIIIII 78.9% No complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since 2010 at a rate over 1.45% per year 18% . . . . . . 83.2% Yes Israel p CESSATION PROGRAMMES: No significant change in affordability of Italy 20% — IIIIIII 76.6% Yes TREATMENT OF TOBACCO DEPENDENCE cigarettes since 2010 Kazakhstan 16% — IIIIIII 55.7% Yes p Data not reported ... Insufficient data to conduct a trend analysis Kyrgyzstan 22% III IIIII 52.9% Yes p None Latvia 30% IIIIIIII IIIIIIIIII 79.9% NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO Lithuania 22% III IIIIIIIIII 74.0% SMOKE-FREE LAWS NRT and/or some cessation services (at least Luxembourg 17% ...... 68.3% one of which is cost-covered) |||||||||| ||||||||| Malta 19% ...... 77.6% No National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| Monaco ...... — ...... cessation services cost-covered ||||||| Montenegro 27% ...... 77.5% Yes p HEALTH WARNINGS: |||||| Netherlands 17% . . . IIIIIIII 77.2% Yes p HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) |||| ...... 80.3% North Macedonia Data not reported ||| Norway 12% IIIIIIIIII IIIIIIIIII 61.6% Yes No warnings or small warnings || Minimal compliance (0/10 to 2/10) Poland 21% IIIIIIII IIIIII 78.4% Medium size warnings missing some | Portugal 20% IIIIIIII IIIIIII 78.6% p appropriate characteristics OR large warnings missing many appropriate characteristics Republic of Moldova 24% ...... 62.4% Yes SYMBOLS LEGEND Medium size warnings with all appropriate Romania 27% IIIIIII IIIIIIII 69.6% characteristics OR large warnings missing Plain packaging is mandated. Russian Federation 27% IIIIIIIII IIIIIIII 56.1% Yes some appropriate characteristics 8 Law adopted but not implemented by San Marino ...... Large warnings with all appropriate 31 December 2020. characteristics qp Change in POWER indicator group, up or down, Serbia 33% III IIIIII 76.5% Yes between 2018 and 2020. Some 2018 data were Slovakia 24% IIIIIIIIII IIIIIIIIII 76.3% Yes revised in 2020. 2020 grouping rules were applied MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Slovenia 20% . . . . . . 78.7% Data not reported ... Data not reported/not available Spain 25% IIIIIIII IIIIIIII 78.2% No national campaign conducted between – Data not required/not applicable Sweden 9% — IIIIIIIIII 68.1% Yes July 2018 and June 2020 with a duration of at Switzerland 21% — . . . 59.6% Yes least 3 weeks Tajikistan . . . III IIIIIIIII 41.9% National campaign conducted with one to four appropriate characteristics Turkey 26% IIIIIII IIIIIIII 84.9% National campaign conducted with five to six Turkmenistan 4% IIIIIIIII IIIIIIIIII 42.2% Yes appropriate characteristics Ukraine 24% IIIIIIII IIIIIIII 69.3% Yes National campaign conducted with at least seven appropriate characteristics including United Kingdom of Great 13% IIIIIIIIII IIIIIIIIII 79.3% Yes Britain and Northern Ireland airing on television and/or radio Uzbekistan 9% ...... 56.3% p Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 147 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY OR TERRITORY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.5 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE Eastern WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 Mediterranean Afghanistan 7% I IIIIIIIII 20.7% Yes Summary of Bahrain 13% — . . . 72.2% Yes ...... MPOWER measures Djibouti Egypt 21% III IIIIIIII 78.5% Iran (Islamic Republic of) 9% IIIIIIIII IIIIIIIIII 15.5% Yes < “Occupied Palestinian territory” Iraq 17% III IIIIIII 7.6% p p should be understood to refer to Jordan 30% — IIIIIII 78.0% Yes p p p the “occupied Palestinian territory, including east Jerusalem” Kuwait 17% ...... 18.9% Yes Lebanon 24% IIIIIII IIIIIIIII 9.9% Libya . . . II IIIIIIIIII 9.4% Yes Morocco 11% IIIII IIIIIIIII 76.1% p occupied Palestinian . . . IIIIII 92.8% Yes territory < Oman 7% — IIIIIIIIII 63.6% Yes q p Pakistan 12% IIIII IIIIIIIII 60.8% Qatar 10% — IIIIIIIIII 68.2% Yes p p Saudi Arabia 11% IIIII IIIIIIIIII 73.8% Yes Somalia . . . — — 7.1% . . . Sudan . . . — IIIIIIII 73.4% No p Syrian Arab Republic ...... 41.8% . . . q Tunisia 21% — IIIIIII 69.6% United Arab Emirates 9% IIIIIIII IIIIIIIII 72.6% Yes Yemen 14% III IIIIII 50.7% Yes
148 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY OR TERRITORY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Afghanistan 7% I IIIIIIIII 20.7% Yes From 20% to 29.9% Bahrain 13% — . . . 72.2% Yes Ban on national television, radio and print From 15% to 19.9% media only Djibouti ...... Less than 15% Ban on national television, radio and print Egypt 21% III IIIIIIII 78.5% * The figures should be used strictly for the purpose of drawing media as well as on some but not all other comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising Iran (Islamic Republic of) 9% IIIIIIIII IIIIIIIIII 15.5% Yes absolute number of daily tobacco smokers in a country. Ban on all forms of direct and indirect Iraq 17% III IIIIIII 7.6% p p MONITORING: PREVALENCE DATA advertising (or at least 90% of the population Jordan 30% — IIIIIII 78.0% Yes p p p covered by subnational legislation completely No known data or no recent data or data Kuwait 17% ...... 18.9% Yes banning tobacco advertising, promotion that are not both recent and representative and sponsorship) Lebanon 24% IIIIIII IIIIIIIII 9.9% Recent and representative data for either Libya . . . II IIIIIIIIII 9.4% Yes adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE Recent and representative data for both OF THE MOST WIDELY SOLD BRAND OF CIGARETTES Morocco 11% IIIII IIIIIIIII 76.1% p adults and youth occupied Palestinian Data not reported . . . IIIIII 92.8% Yes Recent, representative and periodic data territory < for both adults and youth < 25% of retail price is tax Oman 7% — IIIIIIIIII 63.6% Yes q p ≥ 25% and <50% of retail price is tax Pakistan 12% IIIII IIIIIIIII 60.8% SMOKE-FREE ENVIRONMENTS: SMOKING BANS ≥ 50% and <75% of retail price is tax Qatar 10% — IIIIIIIIII 68.2% Yes p p Data not reported ≥ 75% of retail price is tax Saudi Arabia 11% IIIII IIIIIIIIII 73.8% Yes Complete absence of ban, or up to two public places completely smoke-free AFFORDABILITY OF CIGARETTES Somalia . . . — — 7.1% . . . Three to five public places completely smoke-free Sudan . . . — IIIIIIII 73.4% No p Cigarettes less affordable - Trend in per capita Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since Syrian Arab Republic ...... 41.8% . . . q 2010 at a rate over 1.45% per year All public places completely smoke-free (or Tunisia 21% — IIIIIII 69.6% at least 90% of the population covered by Cigarettes more affordable - Trend in per capita United Arab Emirates 9% IIIIIIII IIIIIIIII 72.6% Yes complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since 2010 at a rate over 1.45% per year Yemen 14% III IIIIII 50.7% Yes CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE No significant change in affordability of cigarettes since 2010 Data not reported ... Insufficient data to conduct a trend analysis None NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS NRT and/or some cessation services (at least one of which is cost-covered) |||||||||| ||||||||| National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| cessation services cost-covered ||||||| HEALTH WARNINGS: |||||| HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) |||| Data not reported ||| No warnings or small warnings || Minimal compliance (0/10 to 2/10) Medium size warnings missing some | appropriate characteristics OR large warnings missing many appropriate characteristics SYMBOLS LEGEND Medium size warnings with all appropriate characteristics OR large warnings missing Plain packaging is mandated. some appropriate characteristics 8 Law adopted but not implemented by Large warnings with all appropriate 31 December 2020. characteristics qp Change in POWER indicator group, up or down, between 2018 and 2020. Some 2018 data were revised in 2020. 2020 grouping rules were applied MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Data not reported ... Data not reported/not available No national campaign conducted between – Data not required/not applicable July 2018 and June 2020 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio
Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 149 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
M P O W E R P O W E R COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION Table 1.6 SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS LEVEL OF LEVEL OF TAXATION AFFORDABLE WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 Western COMPLIANCE COMPLIANCE SINCE 2010 Pacific Australia 12% . . . IIIIIIIIII 73.9% Yes q q Brunei Darussalam 12% IIIIIII IIIIIIIII –– Summary of Cambodia 15% IIIIIII IIIIIIII 26.4% No p MPOWER measures China 23% IIIIIIII IIIIIII 54.5% No Cook Islands 17% IIIIIII IIIIIIIIII ...... p Fiji 15% IIIIIII IIIIII 36.9% Yes Japan 17% — — 61.0% Yes p Kiribati 37% IIIIIIII IIIIIIIII 41.4% No
Lao People's 24% IIIIII IIIIIIIIII 11.7% No Democratic Republic Malaysia 17% — IIIIIIII 51.5% Yes Marshall Islands 19% IIIIIII IIIIIIII 54.1% No
Micronesia . . . IIIIIII IIIII 46.7% Yes (Federated States of) Mongolia 23% IIIII IIIIII 45.4% Nauru 37% IIIIIIII IIIIIIIIII 42.2% Yes q New Zealand 13% IIIIIIIIII IIIIIIIIII 82.0% Yes Niue ...... 57.8% . . . q Palau 14% IIIIIIIIII IIIIIIIIII 71.4% Yes Papua New Guinea 35% II III 53.1% q Philippines 18% IIIII IIIIII 55.7% Yes p Republic of Korea 20% IIIII IIIII 73.9% Yes Samoa 20% ...... 49.2% Yes Singapore 14% IIIIIIII IIIIIIIIII 67.1% Solomon Islands 29% III IIIIII ...... Tonga 26% ...... 67.3% Yes p Tuvalu 29% IIIIIIII IIIIIIII 38.7% Vanuatu 12% – IIIIIIII 52.7% Viet Nam 20% IIIII IIIIII 38.8% No
150 | WORLD HEALTH ORGANIZATION 2020 INDICATOR AND COMPLIANCE CHANGE SINCE 2018
ADULT DAILY SMOKING PREVALENCE*: M P O W E R P O W E R AGE-STANDARDIZED PREVALENCE RATES FOR ADULT DAILY ADVERTISING BANS: COUNTRY ADULT DAILY MONITORING SMOKING CESSATION WARNINGS ADVERTISING SMOKING CESSATION HEALTH ADVERTISING TAXATION SMOKING BANS PROGRAMMES BANS BANS PROGRAMMES WARNINGS BANS SMOKERS OF TOBACCO (BOTH SEXES COMBINED), 2019 BANS ON ADVERTISING, PROMOTION AND SPONSORSHIP PREVALENCE (2019) LINES REPRESENT LINES REPRESENT CIGARETTES LESS HEALTH MASS Estimates not available Data not reported LEVEL OF LEVEL OF TAXATION AFFORDABLE . . . WARNINGS MEDIA CHANGE IN POWER INDICATOR GROUP, UP OR DOWN, SINCE 2018 COMPLIANCE COMPLIANCE SINCE 2010 30% or more Complete absence of ban, or ban that does not cover national television, radio and print media Australia 12% . . . IIIIIIIIII 73.9% Yes q q From 20% to 29.9% Brunei Darussalam 12% IIIIIII IIIIIIIII –– Ban on national television, radio and print From 15% to 19.9% media only Cambodia 15% IIIIIII IIIIIIII 26.4% No p Less than 15% Ban on national television, radio and print China 23% IIIIIIII IIIIIII 54.5% No * The figures should be used strictly for the purpose of drawing media as well as on some but not all other comparisons across countries and must not be used to estimate forms of direct and/or indirect advertising Cook Islands 17% IIIIIII IIIIIIIIII ...... p absolute number of daily tobacco smokers in a country. Ban on all forms of direct and indirect Fiji 15% IIIIIII IIIIII 36.9% Yes MONITORING: PREVALENCE DATA advertising (or at least 90% of the population Japan 17% — — 61.0% Yes p covered by subnational legislation completely No known data or no recent data or data Kiribati 37% IIIIIIII IIIIIIIII 41.4% No banning tobacco advertising, promotion that are not both recent and representative and sponsorship) Lao People's 24% IIIIII IIIIIIIIII 11.7% No Recent and representative data for either Democratic Republic adults or youth TAXATION: SHARE OF TOTAL TAXES IN THE RETAIL PRICE Malaysia 17% — IIIIIIII 51.5% Yes Recent and representative data for both OF THE MOST WIDELY SOLD BRAND OF CIGARETTES adults and youth Marshall Islands 19% IIIIIII IIIIIIII 54.1% No Data not reported Recent, representative and periodic data Micronesia . . . IIIIIII IIIII 46.7% Yes < 25% of retail price is tax (Federated States of) for both adults and youth 25% and <50% of retail price is tax Mongolia 23% IIIII IIIIII 45.4% ≥ SMOKE-FREE ENVIRONMENTS: SMOKING BANS 50% and <75% of retail price is tax Nauru 37% IIIIIIII IIIIIIIIII 42.2% Yes q ≥ Data not reported 75% of retail price is tax New Zealand 13% IIIIIIIIII IIIIIIIIII 82.0% Yes ≥ Complete absence of ban, or up to two public Niue ...... 57.8% . . . q places completely smoke-free AFFORDABILITY OF CIGARETTES 14% IIIIIIIIII IIIIIIIIII 71.4% Yes Palau Three to five public places completely smoke-free Cigarettes less affordable - Trend in per capita Papua New Guinea 35% II III 53.1% q Six to seven public places completely smoke-free YES GDP needed to buy cigarettes increased since 2010 at a rate over 1.45% per year Philippines 18% IIIII IIIIII 55.7% Yes p All public places completely smoke-free (or Republic of Korea 20% IIIII IIIII 73.9% Yes at least 90% of the population covered by Cigarettes more affordable - Trend in per capita complete subnational smoke-free legislation) NO GDP needed to buy cigarettes decreased since Samoa 20% ...... 49.2% Yes 2010 at a rate over 1.45% per year Singapore 14% IIIIIIII IIIIIIIIII 67.1% CESSATION PROGRAMMES: TREATMENT OF TOBACCO DEPENDENCE No significant change in affordability of Solomon Islands 29% III IIIIII ...... cigarettes since 2010 Data not reported Tonga 26% ...... 67.3% Yes p ... Insufficient data to conduct a trend analysis None Tuvalu 29% IIIIIIII IIIIIIII 38.7% NRT and/or some cessation services (neither COMPLIANCE: COMPLIANCE WITH BANS ON ADVERTISING, Vanuatu 12% – IIIIIIII 52.7% cost-covered) PROMOTION AND SPONSORSHIP, AND ADHERENCE TO SMOKE-FREE LAWS Viet Nam 20% IIIII IIIIII 38.8% No NRT and/or some cessation services (at least one of which is cost-covered) |||||||||| ||||||||| National quit line, and both NRT and some Complete compliance (8/10 to 10/10) |||||||| cessation services cost-covered ||||||| HEALTH WARNINGS: |||||| HEALTH WARNINGS ON CIGARETTE PACKAGES ||||| Moderate compliance (3/10 to 7/10) |||| Data not reported ||| No warnings or small warnings || Minimal compliance (0/10 to 2/10) Medium size warnings missing some | appropriate characteristics OR large warnings missing many appropriate characteristics SYMBOLS LEGEND Medium size warnings with all appropriate characteristics OR large warnings missing Plain packaging is mandated. some appropriate characteristics 8 Law adopted but not implemented by Large warnings with all appropriate 31 December 2020. characteristics qp Change in POWER indicator group, up or down, between 2018 and 2020. Some 2018 data were revised in 2020. 2020 grouping rules were applied MASS MEDIA: ANTI-TOBACCO CAMPAIGNS to both years. Data not reported ... Data not reported/not available No national campaign conducted between – Data not required/not applicable July 2018 and June 2020 with a duration of at least 3 weeks National campaign conducted with one to four appropriate characteristics National campaign conducted with five to six appropriate characteristics National campaign conducted with at least seven appropriate characteristics including airing on television and/or radio
Please refer to Technical Note I for definitions of categories
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 151 152 | WORLD HEALTH ORGANIZATION ANNEX II REGIONAL SUMMARY OF MEASURES APPLIED TO ENDS
Annex II provides an overview of Annex II provides detailed information Monitoring and taxation of selected tobacco control measures on selected regulatory aspects of ENDS ENDS/ENNDS: applied to ENDS. and ENNDS, for each WHO region. ■ Data on prevalence of ENDS use The following data are reported in For each WHO region an overview table available from national population- this Annex: is presented that includes information based surveys of adults and/or on monitoring and prevalence, ENDS school-based surveys of adolescents Regulation of ENDS/ENNDS: use in public indoor areas, health ■ Excise tax applied on ENDS/ENNDS warnings and packaging, advertising, ■ Bans applied to ENDS/ENNDS e-liquids (closed systems and/or promotion and sponsorship bans, ■ P, W and E measures applied to open systems) taxation levels, age restrictions on sales ENDS/ENNDS and regulations applied to flavours, based on the methodology outlined in ■ Minimum age of sale Technical Notes I, II and III. ■ How flavours are regulated.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 153 COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.1 WARNINGS MEASURE REGULATED Africa Algeria None Partial Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Angola None None None None None Not regulated Regulation of ENDS/ENNDS Benin None None None None None Not regulated * ENNDS are treated the same as ENDS Botswana None None None None None Not regulated — Not applicable because sale is banned Burkina Faso None None None None None Not regulated Burundi None None None None None Not regulated Cabo Verde None None None None None Not regulated Cameroon None None None None None Not regulated Central African Republic None None None None None Not regulated Chad None None None None None Not regulated Comoros None None None None None Not regulated Congo None Full* Partial (e-liquids only)* Full* 18* Not regulated Côte d'Ivoire None None Partial (devices only)* Full (devices only)* 18* Not regulated Democratic Republic of the Congo None None None None None Not regulated Equatorial Guinea None None None None None Not regulated Eritrea None None None None None Not regulated Eswatini None None None None None Not regulated Sales, manufacture, wholesale, distribution, Ethiopia None — None — — offer for sale, import to trade Gabon None None None None None Not regulated Sales, import, manufacture, distribution, Gambia None — None — — possession, offer for sale* Ghana None None None None None Not regulated Guinea None None None None None Not regulated Guinea-Bissau None None None None None Not regulated Kenya None None Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Lesotho None None None None None Not regulated Liberia None None None None None Not regulated Madagascar None None None None None Not regulated Malawi None None None None None Not regulated Mali None None None None None Not regulated Mauritania None None None None None Not regulated Mauritius Sales, offer for sale, distribution* None — None — — Mozambique None None None None None Not regulated Namibia None None None None None Not regulated Niger None None None None None Not regulated Nigeria None None None None None Not regulated Rwanda None None None None None Not regulated Sao Tome and Principe None None None None None Not regulated Senegal None None None None None Not regulated Seychelles None None None None None Not regulated Sierra Leone None None None None None Not regulated South Africa None None None None None Not regulated South Sudan None None None None None Not regulated Togo None Partial Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Sales, import, manufacture, distribution, Uganda None — None — — process, offer for sale, bring into the country* United Republic of Tanzania None None None None None Not regulated Zambia None None None None None Not regulated Zimbabwe None None None None None Not regulated
154 | WORLD HEALTH ORGANIZATION COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Algeria None Partial Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Angola None None None None None Not regulated Benin None None None None None Not regulated Botswana None None None None None Not regulated Burkina Faso None None None None None Not regulated Burundi None None None None None Not regulated Cabo Verde None None None None None Not regulated Cameroon None None None None None Not regulated Central African Republic None None None None None Not regulated Chad None None None None None Not regulated Comoros None None None None None Not regulated Congo None Full* Partial (e-liquids only)* Full* 18* Not regulated Côte d'Ivoire None None Partial (devices only)* Full (devices only)* 18* Not regulated Democratic Republic of the Congo None None None None None Not regulated Equatorial Guinea None None None None None Not regulated Eritrea None None None None None Not regulated Eswatini None None None None None Not regulated Sales, manufacture, wholesale, distribution, Ethiopia None — None — — offer for sale, import to trade Gabon None None None None None Not regulated Sales, import, manufacture, distribution, Gambia None — None — — possession, offer for sale* Ghana None None None None None Not regulated Guinea None None None None None Not regulated Guinea-Bissau None None None None None Not regulated Kenya None None Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Lesotho None None None None None Not regulated Liberia None None None None None Not regulated Madagascar None None None None None Not regulated Malawi None None None None None Not regulated Mali None None None None None Not regulated Mauritania None None None None None Not regulated Mauritius Sales, offer for sale, distribution* None — None — — Mozambique None None None None None Not regulated Namibia None None None None None Not regulated Niger None None None None None Not regulated Nigeria None None None None None Not regulated Rwanda None None None None None Not regulated Sao Tome and Principe None None None None None Not regulated Senegal None None None None None Not regulated Seychelles None None None None None Not regulated Sierra Leone None None None None None Not regulated South Africa None None None None None Not regulated South Sudan None None None None None Not regulated Togo None Partial Partial (e-liquids only) Full (e-liquids only) 18 Not regulated Sales, import, manufacture, distribution, Uganda None — None — — process, offer for sale, bring into the country* United Republic of Tanzania None None None None None Not regulated Zambia None None None None None Not regulated Zimbabwe None None None None None Not regulated
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 155 COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.2 WARNINGS MEASURE REGULATED The Americas Antigua and Barbuda None None None None None Not regulated Sales, import, distribution, commercialization, Argentina Full — Partial — — Regulation of ENDS/ENNDS advertising, promotion
* ENNDS are treated the same as ENDS Bahamas None None None None None Not regulated — Not applicable because sale is banned Barbados None Full None None 18 Not regulated Belize None None None None None Not regulated Bolivia (Plurinational State of) None None None None None Not regulated Brazil Sales, import* Full* — Full* — — Canada None Partial* Partial (e-liquids only) Partial* 18 Not regulated Chile None None None None None Not regulated Colombia None None None None None Not regulated Costa Rica None Full Full Partial 18 Not regulated Cuba None None None None None Not regulated Dominica None None None None None Not regulated Dominican Republic None None None None None Not regulated Ecuador None Full Full Partial 18 Not regulated El Salvador None Full None None None Not regulated Grenada None None None None None Not regulated Guatemala None None None None None Not regulated Guyana None Full* None Full* 18* Not regulated Haiti None None None None None Not regulated Honduras None Full* Full (devices only)* Partial 21* Not regulated Jamaica None Full Full Partial 18 Not regulated Sales, import, distribution, display, Mexico None — None — — promotion, production* Nicaragua None None None None None Not regulated Panama Sales, import* Full* — None — — Paraguay None Full* None Partial* 18* Not regulated Peru None None None None None Not regulated Saint Kitts and Nevis None None None None None Not regulated Saint Lucia None Full Full None 18 Not regulated Saint Vincent and the Grenadines None None None None None Not regulated Suriname Sales, import, distribution* None — None — — Trinidad and Tobago None None None None None Not regulated United States of America None None Partial (e-liquids only) Partial 21 Not regulated Sales, commercialisation, importation, Uruguay Full* — Full* — — registration as a trademark or patent* Venezuela (Bolivarian Republic of) Sales, promotion, commercialisation* None — None — —
156 | WORLD HEALTH ORGANIZATION COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Antigua and Barbuda None None None None None Not regulated Sales, import, distribution, commercialization, Argentina Full — Partial — — advertising, promotion Bahamas None None None None None Not regulated Barbados None Full None None 18 Not regulated Belize None None None None None Not regulated Bolivia (Plurinational State of) None None None None None Not regulated Brazil Sales, import* Full* — Full* — — Canada None Partial* Partial (e-liquids only) Partial* 18 Not regulated Chile None None None None None Not regulated Colombia None None None None None Not regulated Costa Rica None Full Full Partial 18 Not regulated Cuba None None None None None Not regulated Dominica None None None None None Not regulated Dominican Republic None None None None None Not regulated Ecuador None Full Full Partial 18 Not regulated El Salvador None Full None None None Not regulated Grenada None None None None None Not regulated Guatemala None None None None None Not regulated Guyana None Full* None Full* 18* Not regulated Haiti None None None None None Not regulated Honduras None Full* Full (devices only)* Partial 21* Not regulated Jamaica None Full Full Partial 18 Not regulated Sales, import, distribution, display, Mexico None — None — — promotion, production* Nicaragua None None None None None Not regulated Panama Sales, import* Full* — None — — Paraguay None Full* None Partial* 18* Not regulated Peru None None None None None Not regulated Saint Kitts and Nevis None None None None None Not regulated Saint Lucia None Full Full None 18 Not regulated Saint Vincent and the Grenadines None None None None None Not regulated Suriname Sales, import, distribution* None — None — — Trinidad and Tobago None None None None None Not regulated United States of America None None Partial (e-liquids only) Partial 21 Not regulated Sales, commercialisation, importation, Uruguay Full* — Full* — — registration as a trademark or patent* Venezuela (Bolivarian Republic of) Sales, promotion, commercialisation* None — None — —
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 157 COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.3 WARNINGS MEASURE REGULATED South-East Asia Bangladesh None None None None None Not regulated Regulation of ENDS/ENNDS Bhutan None None None None None Not regulated Democratic People's Republic of Korea Sales, import, export* None — None — — * ENNDS are treated the same as ENDS Sales, production, manufacture, import, India None — Partial* — — — Not applicable because sale is banned export, transport, distribution, storage* Indonesia None None None None None Not regulated Maldives None None None None None Not regulated Myanmar None None None None None Not regulated Manufacture, import, distribute, promote Nepal Full* None Full (devices only)* 18* Not regulated (bans restricted to some places only) Sri Lanka Sales, manufacture, import, offer for sale None — None — — Thailand Sales, import* None — None — — Timor-Leste Sales, import* None — None — —
158 | WORLD HEALTH ORGANIZATION COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Bangladesh None None None None None Not regulated Bhutan None None None None None Not regulated Democratic People's Republic of Korea Sales, import, export* None — None — — Sales, production, manufacture, import, India None — Partial* — — export, transport, distribution, storage* Indonesia None None None None None Not regulated Maldives None None None None None Not regulated Myanmar None None None None None Not regulated Manufacture, import, distribute, promote Nepal Full* None Full (devices only)* 18* Not regulated (bans restricted to some places only) Sri Lanka Sales, manufacture, import, offer for sale None — None — — Thailand Sales, import* None — None — — Timor-Leste Sales, import* None — None — —
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 159 COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.4 WARNINGS MEASURE REGULATED Europe Albania None Full* None None 18* Not regulated Andorra None Partial None None 18* Not regulated Regulation of ENDS/ENNDS Armenia None Partial Full Partial 18 Not regulated * ENNDS are treated the same as ENDS Austria None Partial* Partial Partial* 18* Not regulated 8 Provision adopted but not implemented by 31 December 2020 Azerbaijan None Partial* None Full (devices only)* 18* Not regulated — Not applicable because sale is banned Belarus None Partial* None Partial* 18* Not regulated Belgium None Partial* Partial Partial 18* Not regulated Bosnia and Herzegovina None None None None None Not regulated Bulgaria None None Partial Partial 18 Not regulated Croatia None Partial Partial Partial 18 Not regulated Cyprus None Partial* Partial Partial* 18* Not regulated Czechia None Partial* Partial Partial* 18* Not regulated Some specific flavours Denmark None Partial* Partial Partial* 18* are allowed*8 Some specific flavours Estonia None Partial* Partial Partial* 18* are allowed Finland None Partial* Partial (e-liquids only) Full* 18* All flavours are banned* France None Partial* Partial Partial* 18 Not regulated Georgia None Partial None Partial 18 Not regulated Some specific flavours Germany None None Partial Partial 18 are banned Greece None Full* Partial Partial* 18* Not regulated Hungary None Partial* Partial Partial 18* All flavours are banned* Iceland None Partial* None Full* 18* Not regulated Ireland None None Partial Partial None Not regulated Israel None Partial Partial Partial 18 Not regulated Italy None Partial Partial Partial 18 Not regulated Kazakhstan None Partial* None None 21* Not regulated Kyrgyzstan None None None None None Not regulated Latvia None Partial* Partial Partial* 18* Not regulated Lithuania None Partial Partial Partial 18 Not regulated Luxembourg None Partial* Partial* Partial* 18* Not regulated Malta None Full* Partial Partial* 18* Not regulated Monaco None None None None None Not regulated Montenegro None Partial* Partial Partial* None All flavours are banned* Netherlands None Partial* Partial* Partial* 18* Not regulated North Macedonia None None None None None Not regulated Norway None Full* Partial Partial* 18* Not regulated Poland None Partial Partial Partial 18 Not regulated Portugal None Partial Partial Partial 18 Not regulated Republic of Moldova None Partial Partial Full 18 Not regulated Romania None Partial Partial Partial None Not regulated Russian Federation None Full* None Full* 18* Not regulated San Marino None Partial* None None 18* Not regulated Serbia None None None Partial* None Not regulated Slovakia None None Partial Partial 18 Not regulated Slovenia None Partial* Partial Full 18* Not regulated Spain None Partial Partial Partial 18 Not regulated Sweden None None Partial Partial 18 Not regulated Switzerland None None None None None Not regulated Tajikistan None Full Full Partial 18 Not regulated Turkey Import (except for personal consumption) Full* Full (devices only)* Full (devices only)* 18* Not regulated Turkmenistan Sales* None — None — — Ukraine None Partial* None None None Not regulated United Kingdom of Great Britain None None Partial Partial None Not regulated and Northern Ireland Uzbekistan None Partial* None Partial (devices only)* None Not regulated
160 | WORLD HEALTH ORGANIZATION COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Albania None Full* None None 18* Not regulated Andorra None Partial None None 18* Not regulated Armenia None Partial Full Partial 18 Not regulated Austria None Partial* Partial Partial* 18* Not regulated Azerbaijan None Partial* None Full (devices only)* 18* Not regulated Belarus None Partial* None Partial* 18* Not regulated Belgium None Partial* Partial Partial 18* Not regulated Bosnia and Herzegovina None None None None None Not regulated Bulgaria None None Partial Partial 18 Not regulated Croatia None Partial Partial Partial 18 Not regulated Cyprus None Partial* Partial Partial* 18* Not regulated Czechia None Partial* Partial Partial* 18* Not regulated Some specific flavours Denmark None Partial* Partial Partial* 18* are allowed*8 Some specific flavours Estonia None Partial* Partial Partial* 18* are allowed Finland None Partial* Partial (e-liquids only) Full* 18* All flavours are banned* France None Partial* Partial Partial* 18 Not regulated Georgia None Partial None Partial 18 Not regulated Some specific flavours Germany None None Partial Partial 18 are banned Greece None Full* Partial Partial* 18* Not regulated Hungary None Partial* Partial Partial 18* All flavours are banned* Iceland None Partial* None Full* 18* Not regulated Ireland None None Partial Partial None Not regulated Israel None Partial Partial Partial 18 Not regulated Italy None Partial Partial Partial 18 Not regulated Kazakhstan None Partial* None None 21* Not regulated Kyrgyzstan None None None None None Not regulated Latvia None Partial* Partial Partial* 18* Not regulated Lithuania None Partial Partial Partial 18 Not regulated Luxembourg None Partial* Partial* Partial* 18* Not regulated Malta None Full* Partial Partial* 18* Not regulated Monaco None None None None None Not regulated Montenegro None Partial* Partial Partial* None All flavours are banned* Netherlands None Partial* Partial* Partial* 18* Not regulated North Macedonia None None None None None Not regulated Norway None Full* Partial Partial* 18* Not regulated Poland None Partial Partial Partial 18 Not regulated Portugal None Partial Partial Partial 18 Not regulated Republic of Moldova None Partial Partial Full 18 Not regulated Romania None Partial Partial Partial None Not regulated Russian Federation None Full* None Full* 18* Not regulated San Marino None Partial* None None 18* Not regulated Serbia None None None Partial* None Not regulated Slovakia None None Partial Partial 18 Not regulated Slovenia None Partial* Partial Full 18* Not regulated Spain None Partial Partial Partial 18 Not regulated Sweden None None Partial Partial 18 Not regulated Switzerland None None None None None Not regulated Tajikistan None Full Full Partial 18 Not regulated Turkey Import (except for personal consumption) Full* Full (devices only)* Full (devices only)* 18* Not regulated Turkmenistan Sales* None — None — — Ukraine None Partial* None None None Not regulated United Kingdom of Great Britain None None Partial Partial None Not regulated and Northern Ireland Uzbekistan None Partial* None Partial (devices only)* None Not regulated
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 161 COUNTRY OR TERRITORY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.5 WARNINGS MEASURE REGULATED Eastern Afghanistan None None None None None Not regulated Bahrain Sales, import, distribution* None — None — — Mediterranean Djibouti None None None None None Not regulated Regulation of ENDS/ENNDS Egypt Sales, import, trade* None — None — — Iran (Islamic Republic of) Sales, import, production, supply, export* None — None — — * ENNDS are treated the same as ENDS Iraq Sales, import, trade, manufacture* None — Full* — — — Not applicable because sale is banned Jordan Sales, import, distribution, manufacture* Full* — None — — < “occupied Palestinian territory” should be understood to refer to the “occupied Palestinian territory, including east Jerusalem” Kuwait Sales, trade, import* Partial* — Full* — — Lebanon Sales, import* Full* — Partial* — — Libya None None None None None Not regulated Morocco None None None None None Not regulated occupied Palestinian territory < Sales, import, manufacture * None — None — — Oman Sales, import* None — None — — Pakistan None None None None None Not regulated Sales, import, trade, display, distribution, Qatar None — None — — manufacture* Saudi Arabia None Partial* Partial* None None Flavours are restricted* Somalia None None None None None Not regulated Sudan None None None None None Not regulated Syrian Arab Republic Sales, manufacture, distribution, trade* Partial* — None — — Tunisia None None None None None Not regulated United Arab Emirates None None Partial (e-liquids only)* Full* 18* Not regulated Yemen None None None None None Not regulated
162 | WORLD HEALTH ORGANIZATION COUNTRY OR TERRITORY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Afghanistan None None None None None Not regulated Bahrain Sales, import, distribution* None — None — — Djibouti None None None None None Not regulated Egypt Sales, import, trade* None — None — — Iran (Islamic Republic of) Sales, import, production, supply, export* None — None — — Iraq Sales, import, trade, manufacture* None — Full* — — Jordan Sales, import, distribution, manufacture* Full* — None — — Kuwait Sales, trade, import* Partial* — Full* — — Lebanon Sales, import* Full* — Partial* — — Libya None None None None None Not regulated Morocco None None None None None Not regulated occupied Palestinian territory < Sales, import, manufacture * None — None — — Oman Sales, import* None — None — — Pakistan None None None None None Not regulated Sales, import, trade, display, distribution, Qatar None — None — — manufacture* Saudi Arabia None Partial* Partial* None None Flavours are restricted* Somalia None None None None None Not regulated Sudan None None None None None Not regulated Syrian Arab Republic Sales, manufacture, distribution, trade* Partial* — None — — Tunisia None None None None None Not regulated United Arab Emirates None None Partial (e-liquids only)* Full* 18* Not regulated Yemen None None None None None Not regulated
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 163 COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS Table 2.1.6 WARNINGS MEASURE REGULATED Western Pacific Australia None Partial None None 18 Not regulated Regulation of ENDS/ENNDS Brunei Darussalam Sales, import* Full* — None — — Cambodia Sales, import* None — None — — * ENNDS are treated the same as ENDS China None None None None 18* Not regulated 8 Provision adopted but not implemented by 31 December 2020 Cook Islands None None None None None Not regulated — Not applicable because sale is banned Fiji None Partial* None Partial* 18* Not regulated Japan None None None None None Not regulated Kiribati None None None None None Not regulated Lao People's Democratic Republic None Full* None Partial* 18* Not regulated Malaysia Sales None — None — — Marshall Islands None None None None None Not regulated Micronesia (Federated States of) None None None None None Not regulated Mongolia None None None None None Not regulated Nauru None None None None None Not regulated New Zealand None Full* None Partial* 18* Flavours are restricted*8 Niue None Full* Partial* Full* 21* Not regulated Palau None Partial None Partial 21 Not regulated Papua New Guinea None Full Partial (devices only) Partial (devices only) 18 Not regulated Some specific flavours Philippines None Partial* None Full* 21* are allowed* Republic of Korea None Partial Partial (e-liquids only) Partial (e-liquids only) 19* Not regulated Samoa None None None None None Not regulated Sales, import, distribute, offer for sale, Singapore Full* — Partial* — — possession* Solomon Islands None None None None None Not regulated Tonga None None None None None Not regulated Tuvalu None Partial* Partial* Full* 18* Not regulated Vanuatu None None None None None Not regulated Viet Nam None None None None None Not regulated
164 | WORLD HEALTH ORGANIZATION COUNTRY BANS P – MEASURE W – HEALTH E – MEASURE MINIMUM AGE OF SALE HOW ARE FLAVOURS WARNINGS MEASURE REGULATED
Australia None Partial None None 18 Not regulated Brunei Darussalam Sales, import* Full* — None — — Cambodia Sales, import* None — None — — China None None None None 18* Not regulated Cook Islands None None None None None Not regulated Fiji None Partial* None Partial* 18* Not regulated Japan None None None None None Not regulated Kiribati None None None None None Not regulated Lao People's Democratic Republic None Full* None Partial* 18* Not regulated Malaysia Sales None — None — — Marshall Islands None None None None None Not regulated Micronesia (Federated States of) None None None None None Not regulated Mongolia None None None None None Not regulated Nauru None None None None None Not regulated New Zealand None Full* None Partial* 18* Flavours are restricted*8 Niue None Full* Partial* Full* 21* Not regulated Palau None Partial None Partial 21 Not regulated Papua New Guinea None Full Partial (devices only) Partial (devices only) 18 Not regulated Some specific flavours Philippines None Partial* None Full* 21* are allowed* Republic of Korea None Partial Partial (e-liquids only) Partial (e-liquids only) 19* Not regulated Samoa None None None None None Not regulated Sales, import, distribute, offer for sale, Singapore Full* — Partial* — — possession* Solomon Islands None None None None None Not regulated Tonga None None None None None Not regulated Tuvalu None Partial* Partial* Full* 18* Not regulated Vanuatu None None None None None Not regulated Viet Nam None None None None None Not regulated
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 165 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.1 FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS Africa COUNTRY OF ADULTS OF ADOLESCENTS Monitoring and taxation Algeria No No … … of ENDS/ENNDS Angola No No … … * ENNDS are taxed the same as ENDS Benin No No … … … Data not available Botswana No No … … Burkina Faso No No … … Burundi No No … … Cabo Verde No No … … Cameroon No No … … Central African Republic No No … … Chad No No … … Comoros No No … … Congo No No … … Côte d'Ivoire No No … … Democratic Republic of the Congo No No … … Equatorial Guinea No No … … Eritrea No No … … Eswatini No No … … Ethiopia No No Sale is banned Sale is banned Gabon No No … … Gambia No No Sale is banned Sale is banned Ghana No Yes … … Guinea No No … … Guinea-Bissau No No … … Kenya No No … … Lesotho No No … … Liberia No No … … Madagascar No No … … Malawi No No … … Mali No No … … Mauritania No No … … Mauritius No Yes Sale is banned Sale is banned Mozambique No No … … Namibia No No … … Niger No No … … Nigeria No No … … Rwanda No No … … Sao Tome and Principe No No … … Senegal Yes No … … Seychelles No No … … Sierra Leone No No … … South Africa No No … … South Sudan No No … … Togo No No … … Uganda No No Sale is banned Sale is banned United Republic of Tanzania No No … … Zambia No No … … Zimbabwe No No … …
166 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OF ADULTS OF ADOLESCENTS
Algeria No No … … Angola No No … … Benin No No … … Botswana No No … … Burkina Faso No No … … Burundi No No … … Cabo Verde No No … … Cameroon No No … … Central African Republic No No … … Chad No No … … Comoros No No … … Congo No No … … Côte d'Ivoire No No … … Democratic Republic of the Congo No No … … Equatorial Guinea No No … … Eritrea No No … … Eswatini No No … … Ethiopia No No Sale is banned Sale is banned Gabon No No … … Gambia No No Sale is banned Sale is banned Ghana No Yes … … Guinea No No … … Guinea-Bissau No No … … Kenya No No … … Lesotho No No … … Liberia No No … … Madagascar No No … … Malawi No No … … Mali No No … … Mauritania No No … … Mauritius No Yes Sale is banned Sale is banned Mozambique No No … … Namibia No No … … Niger No No … … Nigeria No No … … Rwanda No No … … Sao Tome and Principe No No … … Senegal Yes No … … Seychelles No No … … Sierra Leone No No … … South Africa No No … … South Sudan No No … … Togo No No … … Uganda No No Sale is banned Sale is banned United Republic of Tanzania No No … … Zambia No No … … Zimbabwe No No … …
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 167 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.2 FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS The Americas COUNTRY OF ADULTS OF ADOLESCENTS Monitoring and taxation Antigua and Barbuda No Yes … … of ENDS/ENNDS Argentina Yes Yes Sale is banned Sale is banned * ENNDS are taxed the same as ENDS Bahamas No No … … … Data not available Barbados No No … … Belize No Yes … … Bolivia (Plurinational State of) Yes Yes … … Brazil No Yes Sale is banned Sale is banned Canada Yes Yes … … Chile Yes No … … Colombia Yes Yes … … Costa Rica Yes No … … Cuba No Yes … … Dominica No No … … Dominican Republic No Yes … … Ecuador Yes Yes … … El Salvador No Yes … … Grenada No Yes … … Guatemala No Yes … … Guyana No Yes … … Haiti No No … … Honduras No No … … Jamaica No Yes … … Mexico Yes No Sale is banned Sale is banned Nicaragua No Yes … … Panama Yes Yes Sale is banned Sale is banned Paraguay No Yes … … Peru No Yes No No Saint Kitts and Nevis No No … … Saint Lucia No Yes … … Saint Vincent and the Grenadines No Yes … … Suriname No Yes Sale is banned Sale is banned Trinidad and Tobago No Yes … … United States of America Yes Yes … … Uruguay Yes Yes Sale is banned Sale is banned Venezuela (Bolivarian Republic of) No Yes Sale is banned Sale is banned
168 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OF ADULTS OF ADOLESCENTS
Antigua and Barbuda No Yes … … Argentina Yes Yes Sale is banned Sale is banned Bahamas No No … … Barbados No No … … Belize No Yes … … Bolivia (Plurinational State of) Yes Yes … … Brazil No Yes Sale is banned Sale is banned Canada Yes Yes … … Chile Yes No … … Colombia Yes Yes … … Costa Rica Yes No … … Cuba No Yes … … Dominica No No … … Dominican Republic No Yes … … Ecuador Yes Yes … … El Salvador No Yes … … Grenada No Yes … … Guatemala No Yes … … Guyana No Yes … … Haiti No No … … Honduras No No … … Jamaica No Yes … … Mexico Yes No Sale is banned Sale is banned Nicaragua No Yes … … Panama Yes Yes Sale is banned Sale is banned Paraguay No Yes … … Peru No Yes No No Saint Kitts and Nevis No No … … Saint Lucia No Yes … … Saint Vincent and the Grenadines No Yes … … Suriname No Yes Sale is banned Sale is banned Trinidad and Tobago No Yes … … United States of America Yes Yes … … Uruguay Yes Yes Sale is banned Sale is banned Venezuela (Bolivarian Republic of) No Yes Sale is banned Sale is banned
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 169 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.3 FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS South-East Asia COUNTRY OF ADULTS OF ADOLESCENTS Monitoring and taxation Bangladesh No No … … of ENDS/ENNDS Bhutan No No … … * ENNDS are taxed the same as ENDS Democratic People's Republic of Korea No No Sale is banned Sale is banned … Data not available India No No Sale is banned Sale is banned 1 Data refer to ENNDS. Indonesia Yes No Yes No1 Maldives No No … … Myanmar No No … … Nepal Yes No … … Sri Lanka No No Sale is banned Sale is banned Thailand No Yes Sale is banned Sale is banned Timor-Leste No No Sale is banned Sale is banned
170 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OF ADULTS OF ADOLESCENTS
Bangladesh No No … … Bhutan No No … … Democratic People's Republic of Korea No No Sale is banned Sale is banned India No No Sale is banned Sale is banned Indonesia Yes No Yes No1 Maldives No No … … Myanmar No No … … Nepal Yes No … … Sri Lanka No No Sale is banned Sale is banned Thailand No Yes Sale is banned Sale is banned Timor-Leste No No Sale is banned Sale is banned
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 171 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.4 FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS Europe COUNTRY OF ADULTS OF ADOLESCENTS Monitoring and taxation Albania No Yes … Yes of ENDS/ENNDS Andorra No No … … * ENNDS are taxed the same as ENDS Armenia No No No No … Data not available Austria Yes Yes No No Azerbaijan No No Yes* Yes* Belarus No No No No Belgium No No No No Bosnia and Herzegovina No No No No Bulgaria Yes Yes No No Croatia No Yes No No Cyprus Yes Yes … Yes* Czechia Yes Yes No No Denmark Yes Yes No No Estonia Yes Yes Yes* Yes* Finland Yes Yes … Yes* France Yes Yes No No Georgia No Yes Yes* Yes* Germany Yes Yes No No Greece Yes Yes Yes* Yes* Hungary Yes Yes Yes* … Iceland Yes Yes No No Ireland Yes Yes No No Israel No No No No Italy Yes Yes Yes Yes Kazakhstan Yes Yes Yes Yes Kyrgyzstan No Yes Yes Yes Latvia Yes Yes … Yes* Lithuania Yes Yes Yes* Yes* Luxembourg Yes No No No Malta Yes Yes No No Monaco No Yes … … Montenegro No Yes … Yes* Netherlands Yes Yes No No North Macedonia No Yes … Yes* Norway No Yes … … Poland Yes Yes No No Portugal No Yes Yes Yes Republic of Moldova No No No No Romania Yes Yes Yes Yes Russian Federation Yes Yes Yes Yes San Marino No Yes … … Serbia Yes Yes Yes* Yes* Slovakia No Yes … No Slovenia Yes Yes … Yes Spain Yes Yes No No Sweden Yes Yes Yes Yes Switzerland Yes Yes … … Tajikistan No No … … Turkey No No … … Turkmenistan No No Sale is banned Sale is banned Ukraine Yes Yes No No United Kingdom of Great Britain and Northern Ireland No No No No Uzbekistan No No No No
172 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OF ADULTS OF ADOLESCENTS
Albania No Yes … Yes Andorra No No … … Armenia No No No No Austria Yes Yes No No Azerbaijan No No Yes* Yes* Belarus No No No No Belgium No No No No Bosnia and Herzegovina No No No No Bulgaria Yes Yes No No Croatia No Yes No No Cyprus Yes Yes … Yes* Czechia Yes Yes No No Denmark Yes Yes No No Estonia Yes Yes Yes* Yes* Finland Yes Yes … Yes* France Yes Yes No No Georgia No Yes Yes* Yes* Germany Yes Yes No No Greece Yes Yes Yes* Yes* Hungary Yes Yes Yes* … Iceland Yes Yes No No Ireland Yes Yes No No Israel No No No No Italy Yes Yes Yes Yes Kazakhstan Yes Yes Yes Yes Kyrgyzstan No Yes Yes Yes Latvia Yes Yes … Yes* Lithuania Yes Yes Yes* Yes* Luxembourg Yes No No No Malta Yes Yes No No Monaco No Yes … … Montenegro No Yes … Yes* Netherlands Yes Yes No No North Macedonia No Yes … Yes* Norway No Yes … … Poland Yes Yes No No Portugal No Yes Yes Yes Republic of Moldova No No No No Romania Yes Yes Yes Yes Russian Federation Yes Yes Yes Yes San Marino No Yes … … Serbia Yes Yes Yes* Yes* Slovakia No Yes … No Slovenia Yes Yes … Yes Spain Yes Yes No No Sweden Yes Yes Yes Yes Switzerland Yes Yes … … Tajikistan No No … … Turkey No No … … Turkmenistan No No Sale is banned Sale is banned Ukraine Yes Yes No No United Kingdom of Great Britain and Northern Ireland No No No No Uzbekistan No No No No
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 173 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.5 FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS Eastern COUNTRY OR TERRITORY OF ADULTS OF ADOLESCENTS Mediterranean Afghanistan No No … … Monitoring and taxation Bahrain No No Yes1 … of ENDS/ENNDS Djibouti No No … … Egypt No No Sale is banned Sale is banned * ENNDS are taxed the same as ENDS Iran (Islamic Republic of) No No Sale is banned Sale is banned … Data not available Iraq No Yes Sale is banned Sale is banned < “occupied Palestinian territory” should be understood to refer to the “occupied Palestinian territory, including east Jerusalem” Jordan No No … Yes2 1 Estimates made are for e-shisha Kuwait No No Sale is banned Sale is banned 2 Jordan has both a ban on sale of ENDS and an excise Lebanon No No Sale is banned Sale is banned 3 Data refer to ENNDS Libya No No … … Morocco No No … Yes3 occupied Palestinian territory < No No Sale is banned Sale is banned Oman No No Sale is banned Sale is banned Pakistan No No Yes … Qatar Yes Yes Sale is banned Sale is banned Saudi Arabia No No … … Somalia No No … … Sudan No No … … Syrian Arab Republic No No Sale is banned Sale is banned Tunisia No No … … United Arab Emirates Yes No Yes* … Yemen No Yes … Yes
174 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OR TERRITORY OF ADULTS OF ADOLESCENTS
Afghanistan No No … … Bahrain No No Yes1 … Djibouti No No … … Egypt No No Sale is banned Sale is banned Iran (Islamic Republic of) No No Sale is banned Sale is banned Iraq No Yes Sale is banned Sale is banned Jordan No No … Yes2 Kuwait No No Sale is banned Sale is banned Lebanon No No Sale is banned Sale is banned Libya No No … … Morocco No No … Yes3 occupied Palestinian territory < No No Sale is banned Sale is banned Oman No No Sale is banned Sale is banned Pakistan No No Yes … Qatar Yes Yes Sale is banned Sale is banned Saudi Arabia No No … … Somalia No No … … Sudan No No … … Syrian Arab Republic No No Sale is banned Sale is banned Tunisia No No … … United Arab Emirates Yes No Yes* … Yemen No Yes … Yes
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 175 DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS Table 2.2.6 FROM NATIONAL SURVEYS
Western Pacific POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS Monitoring and taxation COUNTRY OF ADULTS OF ADOLESCENTS of ENDS/ENNDS Australia Yes Yes … … Brunei Darussalam Yes Yes Sale is banned Sale is banned * ENNDS are taxed the same as ENDS Cambodia No No Sale is banned Sale is banned … Data not available China Yes Yes … … Cook Islands No No … … Fiji No Yes … … Japan No Yes … … Kiribati No Yes … … Lao People's Democratic Republic No Yes … No Malaysia Yes Yes Sale is banned Sale is banned Marshall Islands Yes Yes … … Micronesia (Federated States of) No No … … Mongolia No Yes … … Nauru No No … … New Zealand Yes Yes … … Niue No Yes … … Palau No No … … Papua New Guinea No Yes … … Philippines Yes No … … Republic of Korea Yes Yes Yes … Samoa No No … … Singapore No No Sale is banned Sale is banned Solomon Islands No No … … Tonga No No No No Tuvalu No No … … Vanuatu No Yes … … Viet Nam Yes Yes … …
176 | WORLD HEALTH ORGANIZATION DATA ON PREVALENCE OF ENDS USE ARE AVAILABLE EXCISE TAX IS APPLIED ON ENDS/ENNDS E-LIQUIDS FROM NATIONAL SURVEYS
POPULATION-BASED SURVEYS SCHOOL-BASED SURVEYS CLOSED SYSTEMS OPEN SYSTEMS COUNTRY OF ADULTS OF ADOLESCENTS
Australia Yes Yes … … Brunei Darussalam Yes Yes Sale is banned Sale is banned Cambodia No No Sale is banned Sale is banned China Yes Yes … … Cook Islands No No … … Fiji No Yes … … Japan No Yes … … Kiribati No Yes … … Lao People's Democratic Republic No Yes … No Malaysia Yes Yes Sale is banned Sale is banned Marshall Islands Yes Yes … … Micronesia (Federated States of) No No … … Mongolia No Yes … … Nauru No No … … New Zealand Yes Yes … … Niue No Yes … … Palau No No … … Papua New Guinea No Yes … … Philippines Yes No … … Republic of Korea Yes Yes Yes … Samoa No No … … Singapore No No Sale is banned Sale is banned Solomon Islands No No … … Tonga No No No No Tuvalu No No … … Vanuatu No Yes … … Viet Nam Yes Yes … …
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 177 178 | WORLD HEALTH ORGANIZATION ANNEX III YEAR OF HIGHEST LEVEL OF ACHIEVEMENT IN SELECTED TOBACCO CONTROL MEASURES
Annex III provides information Years of highest level achievement on the year in which respective of the MPOWER measure Raise taxes countries attained the highest level of on tobacco are not included in this achievement for five of the MPOWER Annex. The share of taxes in product measures. Data are shown separately price depends both on tax policy and for each WHO region. on demand and supply factors that affect manufacturing and retail prices. For Monitoring tobacco use the earliest Countries with tax increases might have year assessed is 2007. However, it is seen the share of tax remain unchanged possible that while 2007 is reported or even decline if the non-tax share of as the year of highest achievement for price rose at the same, or a higher rate, some countries, they actually may have complicating the interpretation of the reached this level earlier. year of highest level of achievement.
See Technical Note III for details on the calculation of tax shares.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 179 COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.1 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Africa Algeria 2018 Year of highest level of Angola achievement in selected Benin 2017 2017 Botswana tobacco control measures Burkina Faso 2010 2015 Note: an empty cell indicates that the population Burundi 2018 is not covered by the measure at the highest level Cabo Verde of achievement. Cameroon 2018
* or earlier year Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire 2019 Democratic Republic of the Congo 2018 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia 2019 2019 2019 Gabon Gambia 2016 2019 2016 Ghana 2018 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania 2020 2018 Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2019 2006 Nigeria 2019 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe
180 | WORLD HEALTH ORGANIZATION COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Algeria 2018 Angola Benin 2017 2017 Botswana Burkina Faso 2010 2015 Burundi 2018 Cabo Verde Cameroon 2018 Central African Republic Chad 2010 2015 2010 Comoros Congo 2012 2018 Côte d'Ivoire 2019 Democratic Republic of the Congo 2018 Equatorial Guinea Eritrea 2004 Eswatini Ethiopia 2019 2019 2019 Gabon Gambia 2016 2019 2016 Ghana 2018 2012 Guinea 2012 Guinea-Bissau Kenya 2007 Lesotho Liberia Madagascar 2013 2012 2003 Malawi Mali Mauritania 2020 2018 Mauritius 2008 2008 Mozambique Namibia 2010 2013 Niger 2019 2006 Nigeria 2019 2015 Rwanda Sao Tome and Principe Senegal 2016 2016 Seychelles 2009 2012 2009 Sierra Leone South Africa South Sudan Togo 2012 Uganda 2015 2015 United Republic of Tanzania Zambia Zimbabwe
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 181 COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.2 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Americas Antigua and Barbuda 2018 2018 Year of highest level of Argentina 2011 2012 achievement in selected Bahamas Barbados 2010 2017 tobacco control measures Belize Note: an empty cell indicates that the population Bolivia (Plurinational State of) 2020 2009 is not covered by the measure at the highest level Brazil 2015 2011 2002 2003 2011 of achievement. Canada 2007* 2007 2008 2011 8 Provision adopted but not implemented by Chile 2007* 2013 2006 31 December 2020 Colombia 2008 2009 * or earlier year Costa Rica 2012 2018 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2011 Grenada Guatemala 2008 Guyana 2017 2018 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2014 2009 Nicaragua Panama 2008 2005 2008 Paraguay 2020 Peru 2010 2010 2011 Saint Kitts and Nevis Saint Lucia 2020 2017 Saint Vincent and the Grenadines Suriname 2013 2016 2013 Trinidad and Tobago 2009 2013 United States of America 2007* 2008 2020 8 Uruguay 2008 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 2019
182 | WORLD HEALTH ORGANIZATION COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Antigua and Barbuda 2018 2018 Argentina 2011 2012 Bahamas Barbados 2010 2017 Belize Bolivia (Plurinational State of) 2020 2009 Brazil 2015 2011 2002 2003 2011 Canada 2007* 2007 2008 2011 Chile 2007* 2013 2006 Colombia 2008 2009 Costa Rica 2012 2018 2013 Cuba Dominica Dominican Republic Ecuador 2016 2011 2012 El Salvador 2015 2011 Grenada Guatemala 2008 Guyana 2017 2018 2017 Haiti Honduras 2010 2017 Jamaica 2013 2016 2013 Mexico 2014 2009 Nicaragua Panama 2008 2005 2008 Paraguay 2020 Peru 2010 2010 2011 Saint Kitts and Nevis Saint Lucia 2020 2017 Saint Vincent and the Grenadines Suriname 2013 2016 2013 Trinidad and Tobago 2009 2013 United States of America 2007* 2008 2020 8 Uruguay 2008 2005 2005 2014 Venezuela (Bolivarian Republic of) 2011 2004 2019
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 183 COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.3 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
South-East Asia Bangladesh 2015 Year of highest level of Bhutan achievement in selected Democratic People's Republic of Korea India 2016 2016 tobacco control measures Indonesia 2015 Note: an empty cell indicates that the population Maldives 2010 is not covered by the measure at the highest level Myanmar of achievement. Nepal 2011 2011 2014
* or earlier year Sri Lanka 2012 Thailand 2008 2010 2005 Timor-Leste 2018
184 | WORLD HEALTH ORGANIZATION COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Bangladesh 2015 Bhutan Democratic People's Republic of Korea India 2016 2016 Indonesia 2015 Maldives 2010 Myanmar Nepal 2011 2011 2014 Sri Lanka 2012 Thailand 2008 2010 2005 Timor-Leste 2018
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 185 COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.4 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Europe Albania 2006 2006 Year of highest level of Andorra achievement in selected Armenia 2007* 2016 Austria 2007* 2020 2016 tobacco control measures Azerbaijan 2016 2017 Note: an empty cell indicates that the population Belarus 2016 is not covered by the measure at the highest level Belgium 2007* 2016 of achievement. Bosnia and Herzegovina
* or earlier year Bulgaria 2008 2012 2016 Croatia 2012 2017 Cyprus 2016 2017 Czechia 2010 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 2016 France 2007* 2016 Georgia 2014 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2012 2016 Iceland 2007* 2006 Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2010 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2008 2016 Luxembourg 2010 2016 2017 Malta 2008 2010 2016 Monaco Montenegro 2016 2019 Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2015 2015 Romania 2010 2015 2016 Russian Federation 2012 2013 2014 2013 San Marino Serbia 2012 Slovakia 2008 2018 2016 Slovenia 2008 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2020 2018 2018 Turkey 2007* 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan
186 | WORLD HEALTH ORGANIZATION COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Albania 2006 2006 Andorra Armenia 2007* 2016 Austria 2007* 2020 2016 Azerbaijan 2016 2017 Belarus 2016 Belgium 2007* 2016 Bosnia and Herzegovina Bulgaria 2008 2012 2016 Croatia 2012 2017 Cyprus 2016 2017 Czechia 2010 2018 2016 Denmark 2007* 2011 2016 Estonia 2007* 2016 Finland 2007* 2016 2016 France 2007* 2016 Georgia 2014 2018 Germany 2007* 2016 Greece 2007* 2010 2016 Hungary 2012 2016 Iceland 2007* 2006 Ireland 2007* 2004 2003 2016 Israel Italy 2007* 2016 Kazakhstan 2010 2014 Kyrgyzstan 2014 Latvia 2007* 2016 Lithuania 2008 2016 Luxembourg 2010 2016 2017 Malta 2008 2010 2016 Monaco Montenegro 2016 2019 Netherlands 2007* 2014 2016 North Macedonia 2008 Norway 2007* 2013 Poland 2007* 2016 Portugal 2007* 2015 Republic of Moldova 2013 2015 2015 Romania 2010 2015 2016 Russian Federation 2012 2013 2014 2013 San Marino Serbia 2012 Slovakia 2008 2018 2016 Slovenia 2008 2017 2017 Spain 2007* 2010 2017 2010 Sweden 2007* 2018 2016 Switzerland 2007* Tajikistan 2020 2018 2018 Turkey 2007* 2008 2010 2012 2012 Turkmenistan 2000 2014 Ukraine 2007* 2009 United Kingdom of Great Britain and Northern Ireland 2007* 2006 2016 Uzbekistan
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 187 COUNTRY OR TERRITORY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.5 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Eastern Afghanistan 2015 2015 Bahrain 2011 Mediterranean Djibouti 2008 2007 Year of highest level of Egypt 2010 2008 achievement in selected Iran (Islamic Republic of) 2008 2007 2008 2007 Iraq 2020 tobacco control measures Jordan 2020 2020 2020 Note: an empty cell indicates that the population Kuwait 2012 2016 is not covered by the measure at the highest level Lebanon 2013 2011 of achievement. Libya 2009 2009
* or earlier year Morocco < “occupied Palestinian territory” should be understood to refer occupied Palestinian territory < 2011 to the “occupied Palestinian territory, including east Jerusalem” Oman Pakistan 2009 2017 Qatar 2019 2016 Saudi Arabia 2018 2017 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 Yemen 2013
188 | WORLD HEALTH ORGANIZATION COUNTRY OR TERRITORY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Afghanistan 2015 2015 Bahrain 2011 Djibouti 2008 2007 Egypt 2010 2008 Iran (Islamic Republic of) 2008 2007 2008 2007 Iraq 2020 Jordan 2020 2020 2020 Kuwait 2012 2016 Lebanon 2013 2011 Libya 2009 2009 Morocco occupied Palestinian territory < 2011 Oman Pakistan 2009 2017 Qatar 2019 2016 Saudi Arabia 2018 2017 2017 Somalia Sudan Syrian Arab Republic Tunisia United Arab Emirates 2008 2013 Yemen 2013
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 189 COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO Table 3.1.6 PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Western Pacific Australia 2007* 2005 2004 Year of highest level of Brunei Darussalam 2016 2012 2007 achievement in selected Cambodia 2016 2016 China 2019 tobacco control measures Cook Islands 2008 Note: an empty cell indicates that the population Fiji 2013 is not covered by the measure at the highest level Japan 2007* of achievement. Kiribati 2013
* or earlier year Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2009 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 2018 Palau 2012 Papua New Guinea 2012 Philippines 2007* 2020 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2010 1999 2012 Solomon Islands 2013 Tonga 2020 Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013
190 | WORLD HEALTH ORGANIZATION COUNTRY MONITOR TOBACCO USE AND PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON TOBACCO PREVENTION POLICIES TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO ADVERTISING, PROMOTION AND SPONSORSHIP
Australia 2007* 2005 2004 Brunei Darussalam 2016 2012 2007 Cambodia 2016 2016 China 2019 Cook Islands 2008 Fiji 2013 Japan 2007* Kiribati 2013 Lao People's Democratic Republic 2015 2016 2016 Malaysia 2012 2008 Marshall Islands 2006 Micronesia (Federated States of) Mongolia 2009 2012 2012 Nauru 2009 New Zealand 2007* 2003 2000 2007 Niue 2018 2018 Palau 2012 Papua New Guinea 2012 Philippines 2007* 2020 2014 Republic of Korea 2007* 2006 Samoa 2013 Singapore 2010 1999 2012 Solomon Islands 2013 Tonga 2020 Tuvalu 2008 Vanuatu 2013 2008 Viet Nam 2014 2013
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 191 192 | WORLD HEALTH ORGANIZATION ANNEX IV Highest level of achievement in selected tobacco control measures in the 100 biggest cities in the world
Annex IV provides information on Cities are listed alphabetically. There A number of countries do not appear in whether the populations of the world’s are many ways to define geographically Table 8 of the Demographic Yearbook 100 biggest cities are covered by and measure the size of “a city”. For because they did not report data. selected tobacco control measures at the purposes of this report, we focused Countries missing from the list because the highest level of achievement. on the jurisdictional boundaries of they did not report data, but large cities, since subnational laws will apply enough to potentially qualify for the to populations within jurisdictions. 100 biggest cities list are: Angola, Where a large “city” includes several Chad, Democratic Republic of the jurisdictions or parts of jurisdictions, Congo, Nigeria, Sudan and Viet Nam. it is possible that not everyone in the Refer to Technical Note I for definitions entire “city” is covered by the same of highest level of achievement. laws. We therefore use the list of cities and their populations published in the United Nations Statistics Division Demographic Yearbook, since these are defined jurisdictionally. Please refer to Table 8 at https://unstats.un.org/ unsd/demographic-social/products/dyb/ dyb_2018/ for the source data.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 193 Table 4.1 CITY POPULATION COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COUNTRY Highest level of PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON RAISE TAXES ON TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO TOBACCO ADVERTISING, TOBACCO achievement in selected PROMOTION AND SPONSORSHIP tobacco control measures Abidjan 4 395 243 N Côte d'Ivoire in the 100 biggest cities* Adana 2 216 475 N N N N N Turkey in the world Addis Ababa 4 215 965 N N N Ethiopia Ahmedabad 5 633 927 N N India * Only cities which appear among the top 100 cities sorted by population size, according to the United Nations Statistics Division Aleppo 4 450 000 Syrian Arab Republic Demographic Yearbook 2018 (available at: https://unstats.un.org/ Alexandria 5 163 750 N N N Egypt unsd/demographic/products/dyb/dyb2018/Table08.xls). Algiers 2 712 944 N N Algeria City’s population covered by national Amman 3 728 346 N N Jordan N legislation or policy at the highest level of Ankara 5 445 026 N N N N N Turkey achievement Antalya 2 364 396 N N N N N Turkey City’s population covered by state-level Baku 2 254 175 N Azerbaijan S legislation or policy at the highest level of Bandung 2 525 220 C Indonesia achievement Bangalore 8 495 492 N N India City’s population covered by city-level Bangkok 8 305 218 N N N Thailand C legislation or policy at the highest level of Beijing 18 796 000 C China achievement Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 613 495 N Germany Bogor 5 162 044 Indonesia Notes: An empty cell indicates that the population in Bogotá 8 181 047 N N Colombia the respective city is not covered by the measure at Brasília 2 977 216 N N N N N Brazil the highest level of achievement. Refer to Technical Note I for definitions of highest level of achievement Buenos Aires 13 879 707 N N N Argentina of the respective measure. Bursa 2 936 803 N N N N N Turkey Busan 3 428 923 N Republic of Korea 8 Privision adopted but not implemented by 31 December 2020 Cairo 9 539 673 N N N Egypt Cali 2 445 405 N N Colombia … Data not available Casablanca 3 352 399 N Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N N 8 United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 465 268 N Republic of Korea Damasus Rural (Rif Dimashq) 2 529 000 Syrian Arab Republic Dar es Salaam 5 147 070 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Faisalabad 3 203 846 N N Pakistan Fortaleza 2 609 716 N N N N N Brazil Guadalajara 5 060 750 N N Mexico Guayaquil 2 581 884 N N Ecuador Havana 2 130 517 ...... Cuba Hong Kong SAR 7 451 000 C C C China, Hong Kong SAR Houston 2 303 482 N N 8 United States of America Hyderabad 6 993 262 S N N India Incheon 2 923 047 N Republic of Korea Istanbul 15 029 231 N N N N N Turkey Izmir 4 279 677 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 428 001 C Indonesia Jiddah 3 430 697 N N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 14 910 352 N N Pakistan Kiev 2 893 215 N Ukraine Kolkata 4 496 694 N N India Konya 2 180 149 N N N N N Turkey Lahore 11 126 285 N N Pakistan
194 | WORLD HEALTH ORGANIZATION CITY POPULATION COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COUNTRY
PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON RAISE TAXES ON TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO TOBACCO ADVERTISING, TOBACCO PROMOTION AND SPONSORSHIP
Abidjan 4 395 243 N Côte d'Ivoire Adana 2 216 475 N N N N N Turkey Addis Ababa 4 215 965 N N N Ethiopia Ahmedabad 5 633 927 N N India Aleppo 4 450 000 Syrian Arab Republic Alexandria 5 163 750 N N N Egypt Algiers 2 712 944 N N Algeria Amman 3 728 346 N N Jordan Ankara 5 445 026 N N N N N Turkey Antalya 2 364 396 N N N N N Turkey Baku 2 254 175 N Azerbaijan Bandung 2 525 220 C Indonesia Bangalore 8 495 492 N N India Bangkok 8 305 218 N N N Thailand Beijing 18 796 000 C China Belo Horizonte 2 513 451 N N N N N Brazil Berlin 3 613 495 N Germany Bogor 5 162 044 Indonesia Bogotá 8 181 047 N N Colombia Brasília 2 977 216 N N N N N Brazil Buenos Aires 13 879 707 N N N Argentina Bursa 2 936 803 N N N N N Turkey Busan 3 428 923 N Republic of Korea Cairo 9 539 673 N N N Egypt Cali 2 445 405 N N Colombia Casablanca 3 352 399 N Morocco Chennai 4 646 732 N N India Chicago 2 704 958 N N 8 United States of America Chittagong 2 591 681 N Bangladesh Daegu 2 465 268 N Republic of Korea Damasus Rural (Rif Dimashq) 2 529 000 Syrian Arab Republic Dar es Salaam 5 147 070 United Republic of Tanzania Delhi 11 034 555 N N India Dhaka 8 906 035 N Bangladesh Douala 2 948 464 N Cameroon Faisalabad 3 203 846 N N Pakistan Fortaleza 2 609 716 N N N N N Brazil Guadalajara 5 060 750 N N Mexico Guayaquil 2 581 884 N N Ecuador Havana 2 130 517 ...... Cuba Hong Kong SAR 7 451 000 C C C China, Hong Kong SAR Houston 2 303 482 N N 8 United States of America Hyderabad 6 993 262 S N N India Incheon 2 923 047 N Republic of Korea Istanbul 15 029 231 N N N N N Turkey Izmir 4 279 677 N N N N N Turkey Jaipur 3 046 163 N N India Jakarta 10 428 001 C Indonesia Jiddah 3 430 697 N N N Saudi Arabia Kabul 3 817 241 N N Afghanistan Kanpur 2 768 057 N N India Karachi 14 910 352 N N Pakistan Kiev 2 893 215 N Ukraine Kolkata 4 496 694 N N India Konya 2 180 149 N N N N N Turkey Lahore 11 126 285 N N Pakistan
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 195 CITY POPULATION COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COUNTRY
PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON RAISE TAXES ON TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO TOBACCO ADVERTISING, TOBACCO PROMOTION AND SPONSORSHIP
Lima 10 350 721 N N Peru London 8 135 667 S C N N United Kingdom of Great Britain and Northern Ireland Los Angeles 3 976 322 S N N 8 United States of America Luanda 2 487 444 N Angola Lucknow 2 817 105 N N India Madrid 3 203 157 N N N N Spain Mashhad 3 001 184 N N N Iran (Islamic Republic of) Medan 2 269 588 C Indonesia Medellín 2 529 403 N N Colombia Mexico City 21 800 320 S N N Mexico Monterrey 4 834 971 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 109 861 N Kenya New York 8 537 673 N N 8 United States of America Osaka 2 691 185 Japan Paris 2 206 488 N N France Puebla-Tlaxcala 3 046 766 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N N Philippines Rawalpindi 2 098 231 N N Pakistan Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N N Saudi Arabia Rome 2 873 147 N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 613 962 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 776 305 N Republic of Korea Singapore 5 638 676 N N Singapore Surabaya 2 885 245 Indonesia Surat 4 501 610 N N India Tangerang 3 050 758 Indonesia Tashkent 2 464 933 Uzbekistan Tehran 8 693 706 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 386 157 S N N Mexico Toronto 2 956 024 S N N Canada Yangon 5 211 431 Myanmar Yaounde 2 873 567 N Cameroon Yokohama 3 724 844 Japan
196 | WORLD HEALTH ORGANIZATION CITY POPULATION COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COVERAGE AT THE HIGHEST LEVEL OF ACHIEVEMENT COUNTRY
PROTECT PEOPLE FROM OFFER HELP TO QUIT WARN ABOUT THE ENFORCE BANS ON RAISE TAXES ON TOBACCO SMOKE TOBACCO USE DANGERS OF TOBACCO TOBACCO ADVERTISING, TOBACCO PROMOTION AND SPONSORSHIP
Lima 10 350 721 N N Peru London 8 135 667 S C N N United Kingdom of Great Britain and Northern Ireland Los Angeles 3 976 322 S N N 8 United States of America Luanda 2 487 444 N Angola Lucknow 2 817 105 N N India Madrid 3 203 157 N N N N Spain Mashhad 3 001 184 N N N Iran (Islamic Republic of) Medan 2 269 588 C Indonesia Medellín 2 529 403 N N Colombia Mexico City 21 800 320 S N N Mexico Monterrey 4 834 971 S N N Mexico Moscow 11 918 057 N N N Russian Federation Mumbai 12 442 373 N N India Nagoya 2 295 638 Japan Nagpur 2 405 665 N N India Nairobi 3 109 861 N Kenya New York 8 537 673 N N 8 United States of America Osaka 2 691 185 Japan Paris 2 206 488 N N France Puebla-Tlaxcala 3 046 766 N N Mexico Pune 3 124 458 N N India Pyongyang 2 581 076 Democratic People's Republic of Korea Quezon City 2 936 116 N N Philippines Rawalpindi 2 098 231 N N Pakistan Rio De Janeiro 6 498 837 N N N N N Brazil Riyadh 5 188 286 N N N Saudi Arabia Rome 2 873 147 N N Italy Saint Petersburg 4 990 602 N N N Russian Federation Salvador 2 938 092 N N N N N Brazil Santiago 5 613 962 N N N Chile São Paulo 12 038 175 N N N N N Brazil Seoul 9 776 305 N Republic of Korea Singapore 5 638 676 N N Singapore Surabaya 2 885 245 Indonesia Surat 4 501 610 N N India Tangerang 3 050 758 Indonesia Tashkent 2 464 933 Uzbekistan Tehran 8 693 706 N N N Iran (Islamic Republic of) Tokyo 9 272 740 Japan Toluca 2 386 157 S N N Mexico Toronto 2 956 024 S N N Canada Yangon 5 211 431 Myanmar Yaounde 2 873 567 N Cameroon Yokohama 3 724 844 Japan
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 197 198 | WORLD HEALTH ORGANIZATION ANNEX V STATUS OF THE WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL AND OF THE PROTOCOL TO ELIMINATE ILLICIT TRADE IN TOBACCO PRODUCTS
Annex V shows the status of the The WHO FCTC entered into force on WHO Framework Convention on 27 February 2005. The treaty remains Tobacco Control (WHO FCTC) and open for ratification, acceptance, of the Protocol to Eliminate Illicit approval, formal confirmation and Trade in Tobacco Products. accession indefinitely for States and eligible regional economic integration Ratification is the international act organizations wishing to become by which countries that have already Parties to it. signed a convention formally state their consent to be bound by it. Accession The Protocol to Eliminate Illicit Trade is the international act by which in Tobacco Products entered into force countries that have not signed a treaty/ on 25 September 2018. It is subject convention formally state their consent to ratification, acceptance, approval to be bound by it. Acceptance and or accession by States and to formal approval are the legal equivalent to confirmation or accession by regional ratification. Signature of a convention economic integration organizations indicates that a country is not legally that are Party to the WHO Framework bound by the treaty but is committed Convention on Tobacco Control. not to undermine its provisions.
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 199 COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* Table 5.1 (OR LEGAL EQUIVALENT) Status of the WHO Afghanistan 29 Jun 2004 13 Aug 2010 Framework Convention Albania 29 Jun 2004 26 Apr 2006 Algeria 20 Jun 2003 30 Jun 2006 on Tobacco Control as Andorra 11 May 2020 a at 1 June 2021 Angola 29 Jun 2004 20 Sep 2007 Antigua and Barbuda 28 Jun 2004 5 Jun 2006 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their Argentina 25 Sep 2003 consent to be bound by it. Armenia 29 Nov 2004 a a Accession is the international act by which countries that have Australia 5 Dec 2003 27 Oct 2004 not signed a treaty/convention formally state their consent to be bound by it. Austria 28 Aug 2003 15 Sep 2005 A Acceptance is the international act, similar to ratification, by Azerbaijan 1 Nov 2005 a which countries that have already signed a treaty/convention Bahamas 29 Jun 2004 3 Nov 2009 formally state their consent to be bound by it. Bahrain 20 Mar 2007 a AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention Bangladesh 16 Jun 2003 14 Jun 2004 formally state their consent to be bound by it. Barbados 28 Jun 2004 3 Nov 2005 c Formal confirmation is the international act corresponding to Belarus 17 Jun 2004 8 Sep 2005 ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic Belgium 22 Jan 2004 1 Nov 2005 integration organizations) formally state their consent to be Belize 26 Sep 2003 15 Dec 2005 bound by a treaty/convention. Benin 18 Jun 2004 3 Nov 2005 d Succession is the international act, however phrased or named, by which successor States formally state their consent Bhutan 9 Dec 2003 23 Aug 2004 to be bound by treaties/conventions originally entered. Bolivia (Plurinational State of) 27 Feb 2004 15 Sep 2005 Bosnia and Herzegovina 10 Jul 2009 a Botswana 16 Jun 2003 31 Jan 2005 Brazil 16 Jun 2003 3 Nov 2005 Brunei Darussalam 3 Jun 2004 3 Jun 2004 Bulgaria 22 Dec 2003 7 Nov 2005 Burkina Faso 22 Dec 2003 31 Jul 2006 Burundi 16 Jun 2003 22 Nov 2005 Cabo Verde 17 Feb 2004 4 Oct 2005 Cambodia 25 May 2004 15 Nov 2005 Cameroon 13 May 2004 3 Feb 2006 Canada 15 Jul 2003 26 Nov 2004 Central African Republic 29 Dec 2003 7 Nov 2005 Chad 22 Jun 2004 30 Jan 2006 Chile 25 Sep 2003 13 Jun 2005 China 10 Nov 2003 11 Oct 2005 Colombia 10 Apr 2008 a Comoros 27 Feb 2004 24 Jan 2006 Congo 23 Mar 2004 6 Feb 2007 Cook Islands 14 May 2004 14 May 2004 Costa Rica 3 Jul 2003 21 Aug 2008 Côte d'Ivoire 24 Jul 2003 13 Aug 2010 Croatia 2 Jun 2004 14 Jul 2008 Cuba 29 Jun 2004 Cyprus 24 May 2004 26 Oct 2005 Czechia 16 Jun 2003 1 Jun 2012 Democratic People's Republic of Korea 17 Jun 2003 27 Apr 2005 Democratic Republic of the Congo 28 Jun 2004 28 Oct 2005 Denmark 16 Jun 2003 16 Dec 2004 Djibouti 13 May 2004 31 Jul 2005 Dominica 29 Jun 2004 24 Jul 2006 Ecuador 22 Mar 2004 25 Jul 2006 Egypt 17 Jun 2003 25 Feb 2005 El Salvador 18 Mar 2004 21 Jul 2014 Equatorial Guinea 17 Sep 2005 a Estonia 8 Jun 2004 27 Jul 2005 Eswatini 29 Jun 2004 13 Jan 2006 Ethiopia 25 Feb 2004 25 Mar 2014 Fiji 3 Oct 2003 3 Oct 2003
200 | WORLD HEALTH ORGANIZATION COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EQUIVALENT)
Finland 16 Jun 2003 24 Jan 2005 France 16 Jun 2003 19 Oct 2004 AA Gabon 22 Aug 2003 20 Feb 2009 Gambia 16 Jun 2003 18 Sep 2007 Georgia 20 Feb 2004 14 Feb 2006 Germany 24 Oct 2003 16 Dec 2004 Ghana 20 Jun 2003 29 Nov 2004 Greece 16 Jun 2003 27 Jan 2006 Grenada 29 Jun 2004 14 Aug 2007 Guatemala 25 Sep 2003 16 Nov 2005 Guinea 1 Apr 2004 7 Nov 2007 Guinea-Bissau 7 Nov 2008 a Guyana 15 Sep 2005 a Haiti 23 Jul 2003 Honduras 18 Jun 2004 16 Feb 2005 Hungary 16 Jun 2003 7 Apr 2004 Iceland 16 Jun 2003 14 Jun 2004 India 10 Sep 2003 5 Feb 2004 Iran (Islamic Republic of) 16 Jun 2003 6 Nov 2005 Iraq 29 Jun 2004 17 Mar 2008 Ireland 16 Sep 2003 7 Nov 2005 Israel 20 Jun 2003 24 Aug 2005 Italy 16 Jun 2003 2 Jul 2008 Jamaica 24 Sep 2003 7 Jul 2005 Japan 9 Mar 2004 8 Jun 2004 A Jordan 28 May 2004 19 Aug 2004 Kazakhstan 21 Jun 2004 22 Jan 2007 Kenya 25 Jun 2004 25 Jun 2004 Kiribati 27 Apr 2004 15 Sep 2005 Kuwait 16 Jun 2003 12 May 2006 Kyrgyzstan 18 Feb 2004 25 May 2006 Lao People's Democratic Republic 29 Jun 2004 6 Sep 2006 Latvia 10 May 2004 10 Feb 2005 Lebanon 4 Mar 2004 7 Dec 2005 Lesotho 23 Jun 2004 14 Jan 2005 Liberia 25 Jun 2004 15 Sep 2009 Libya 18 Jun 2004 7 Jun 2005 Lithuania 22 Sep 2003 16 Dec 2004 Luxembourg 16 Jun 2003 30 Jun 2005 Madagascar 24 Sep 2003 22 Sep 2004 Malaysia 23 Sep 2003 16 Sep 2005 Maldives 17 May 2004 20 May 2004 Mali 23 Sep 2003 19 Oct 2005 Malta 16 Jun 2003 24 Sep 2003 Marshall Islands 16 Jun 2003 8 Dec 2004 Mauritania 24 Jun 2004 28 Oct 2005 Mauritius 17 Jun 2003 17 May 2004 Mexico 12 Aug 2003 28 May 2004 Micronesia (Federated States of) 28 Jun 2004 18 Mar 2005 Mongolia 16 Jun 2003 27 Jan 2004 Montenegro 23 Oct 2006 d Morocco 16 Apr 2004 Mozambique 18 Jun 2003 14 Jul 2017 Myanmar 23 Oct 2003 21 Apr 2004 Namibia 29 Jan 2004 7 Nov 2005 Nauru 29 Jun 2004 a Nepal 3 Dec 2003 7 Nov 2006 Netherlands 16 Jun 2003 27 Jan 2005 A New Zealand 16 Jun 2003 27 Jan 2004
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 201 COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* Table 5.1 (OR LEGAL EQUIVALENT)
Status of the WHO Nicaragua 7 Jun 2004 9 Apr 2008 Framework Convention Niger 28 Jun 2004 25 Aug 2005 Nigeria 28 Jun 2004 20 Oct 2005 on Tobacco Control as Niue 18 Jun 2004 3 Jun 2005 at 1 June 2021 (continued) North Macedonia 30 Jun 2006 a Norway 16 Jun 2003 16 Jun 2003 AA * Ratification is the international act by which countries that have already signed a treaty or convention formally state their Oman 9 Mar 2005 a consent to be bound by it. Pakistan 18 May 2004 3 Nov 2004 a Accession is the international act by which countries that have Palau 16 Jun 2003 12 Feb 2004 not signed a treaty/convention formally state their consent to be bound by it. Panama 26 Sep 2003 16 Aug 2004 A Acceptance is the international act, similar to ratification, by Papua New Guinea 22 Jun 2004 25 May 2006 which countries that have already signed a treaty/convention formally state their consent to be bound by it. Paraguay 16 Jun 2003 26 Sep 2006 Peru 21 Apr 2004 30 Nov 2004 AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention Philippines 23 Sep 2003 6 Jun 2005 formally state their consent to be bound by it. Poland 14 Jun 2004 15 Sep 2006 c Formal confirmation is the international act corresponding to Portugal 9 Jan 2004 8 Nov 2005 AA ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic Qatar 17 Jun 2003 23 Jul 2004 integration organizations) formally state their consent to be bound by a treaty/convention. Republic of Korea 21 Jul 2003 16 May 2005 Republic of Moldova 29 Jun 2004 3 Feb 2009 d Succession is the international act, however phrased or named, by which successor States formally state their consent Romania 25 Jun 2004 27 Jan 2006 to be bound by treaties/conventions originally entered. Russian Federation 3 Jun 2008 a Rwanda 2 Jun 2004 19 Oct 2005 Samoa 25 Sep 2003 3 Nov 2005 San Marino 26 Sep 2003 7 Jul 2004 Sao Tome and Principe 18 Jun 2004 12 Apr 2006 Saudi Arabia 24 Jun 2004 9 May 2005 Senegal 19 Jun 2003 27 Jan 2005 Serbia 28 Jun 2004 8 Feb 2006 Seychelles 11 Sep 2003 12 Nov 2003 Sierra Leone 22 May 2009 a Singapore 29 Dec 2003 14 May 2004 Slovakia 19 Dec 2003 4 May 2004 Slovenia 25 Sep 2003 15 Mar 2005 Solomon Islands 18 Jun 2004 10 Aug 2004 South Africa 16 Jun 2003 19 Apr 2005 Spain 16 Jun 2003 11 Jan 2005 Sri Lanka 23 Sep 2003 11 Nov 2003 Saint Kitts and Nevis 29 Jun 2004 21 Jun 2011 Saint Lucia 29 Jun 2004 7 Nov 2005 Saint Vincent and the Grenadines 14 Jun 2004 29 Oct 2010 Sudan 10 Jun 2004 31 Oct 2005 Suriname 24 Jun 2004 16 Dec 2008 Sweden 16 Jun 2003 7 Jul 2005 Switzerland 25 Jun 2004 Syrian Arab Republic 11 Jul 2003 22 Nov 2004 Tajikistan 21 Jun 2013 a Thailand 20 Jun 2003 8 Nov 2004 Timor-Leste 25 May 2004 22 Dec 2004 Togo 12 May 2004 15 Nov 2005 Tonga 25 Sep 2003 8 Apr 2005 Trinidad and Tobago 27 Aug 2003 19 Aug 2004 Tunisia 22 Aug 2003 7 Jun 2010 Turkey 28 Apr 2004 31 Dec 2004 Turkmenistan 13 May 2011 a Tuvalu 10 Jun 2004 26 Sep 2005 Uganda 5 Mar 2004 20 Jun 2007 Ukraine 25 Jun 2004 6 Jun 2006 United Arab Emirates 24 Jun 2004 7 Nov 2005
202 | WORLD HEALTH ORGANIZATION COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EQUIVALENT)
United Kingdom of Great Britain 16 Jun 2003 16 Dec 2004 and Northern Ireland United Republic of Tanzania 27 Jan 2004 30 Apr 2007 United States of America 10 May 2004 Uruguay 19 Jun 2003 9 Sep 2004 Uzbekistan 15 May 2012 a Vanuatu 22 Apr 2004 16 Sep 2005 Venezuela (Bolivarian Republic of) 22 Sep 2003 27 Jun 2006 Viet Nam 3 Sep 2003 17 Dec 2004 Yemen 20 Jun 2003 22 Feb 2007 Zambia 23 May 2008 a Zimbabwe 4 Dec 2014 a Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX- 4&chapter=9&clang=_en, accessed 11 June 2021). Though not a Member State of WHO, as a Member State of the United Nations, Liechtenstein is also eligible to become Party to the WHO FCTC, though it has taken no action to do so. On submitting instruments to become Party to the WHO FCTC, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&clang=_en
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 203 COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* Table 5.2 (OR LEGAL EQUIVALENT) Status of the Protocol to Austria 9 Jan 2014 28 Oct 2014 Eliminate Illicit Trade in Belgium 17 May 2013 22 Feb 2019 Benin 24 Sep 2013 6 Jul 2018 Tobacco Products as at Botswana 1 Oct 2013 1 June 2021 Brazil 14 Jun 2018 a Burkina Faso 8 Mar 2013 30 Mar 2016 * Ratification is the international act by which countries that have already signed a treaty or convention formally state their Cabo Verde 16 Oct 2019 a consent to be bound by it. Chad 13 Jun 2018 a a Accession is the international act by which countries that have China 10 Jan 2013 not signed a treaty/convention formally state their consent to be bound by it. Colombia 21 Feb 2013 A Acceptance is the international act, similar to ratification, by Comoros 14 Oct 2016 a which countries that have already signed a treaty/convention Congo 14 May 2015 a formally state their consent to be bound by it. Costa Rica 21 Mar 2013 7 Mar 2017 AA Approval is the international act, similar to ratification, by which countries that have already signed a treaty/convention Côte d'Ivoire 24 Sep 2013 25 May 2016 formally state their consent to be bound by it. Croatia 10 Jun 2019 a c Formal confirmation is the international act corresponding to Cyprus 23 Oct 2013 29 Aug 2017 ratification by a State, whereby an international organization (in the case of the WHO FCTC, competent regional economic Czechia 12 Jul 2019 a integration organizations) formally state their consent to be Democratic Republic of the Congo 9 Dec 2013 bound by a treaty/convention. Denmark 7 Jan 2014 d Succession is the international act, however phrased or named, by which successor States formally state their consent Ecuador 25 Sep 2013 15 Oct 2015 to be bound by treaties/conventions originally entered. Egypt 10 Sep 2020 a Eswatini 21 Sep 2016 a Fiji 11 Jul 2013 24 Apr 2019 Finland 25 Sep 2013 France 10 Jan 2013 30 Nov 2015 Gabon 10 Jan 2013 1 Oct 2014 A Gambia 26 Sep 2016 a Germany 1 Oct 2013 31 Oct 2017 Ghana 24 Sep 2013 Greece 9 Jul 2013 24 May 2021 Guinea 9 May 2017 a Guinea-Bissau 24 Sep 2013 Hungary 23 Jun 2020 a India 5 Jun 2018 a Iran (Islamic Republic of) 7 Jan 2014 27 Aug 2018 Iraq 2 Dec 2015 a Ireland 20 Dec 2013 Israel 23 Dec 2013 Kenya 29 May 2013 4 May 2020 Kuwait 11 Nov 2013 21 Feb 2019 Latvia 4 Feb 2016 a Libya 10 Jan 2013 Lithuania 6 Sep 2013 14 Dec 2016 Luxembourg 25 Jul 2019 a Madagascar 25 Sep 2013 21 Sep 2017 Mali 8 Jan 2014 17 Jun 2016 Malta 2 Aug 2018 a Mauritius 26 Jun 2018 a Mongolia 1 Nov 2013 8 Oct 2014 Montenegro 1 Jul 2013 11 Oct 2017 Myanmar 10 Jan 2013 Netherlands 6 Jan 2014 3 Jul 2020 A Nicaragua 10 Jan 2013 20 Dec 2013 Niger 12 Jul 2017 a Nigeria 8 Mar 2019 a North Macedonia 8 Jan 2014 Norway 16 Oct 2013 29 Jun 2018 Pakistan 29 Jun 2018 a Panama 10 Jan 2013 23 Sep 2016
204 | WORLD HEALTH ORGANIZATION COUNTRY DATE OF SIGNATURE DATE OF RATIFICATION* (OR LEGAL EQUIVALENT)
Portugal 8 Jan 2014 22 Jul 2015 Qatar 18 Jun 2013 2 Jul 2018 Republic of Korea 10 Jan 2013 Samoa 29 Jun 2018 a Saudi Arabia 9 Oct 2015 a Senegal 31 Aug 2016 a Serbia 30 Jun 2017 a Seychelles 7 Jan 2020 a Slovakia 25 Sep 2017 a Slovenia 6 Jan 2014 South Africa 10 Jan 2013 Spain 23 Dec 2014 a Sri Lanka 8 Feb 2016 a Sudan 30 Sep 2013 Sweden 6 Jan 2014 9 Jul 2019 Syrian Arab Republic 10 Jan 2013 Togo 9 Jan 2014 31 Jan 2018 Tunisia 11 Jan 2013 Turkey 10 Jan 2013 26 Apr 2018 Turkmenistan 30 Mar 2015 a United Kingdom of Great Britain 17 Dec 2013 27 Jun 2018 and Northern Ireland United Republic of Tanzania 24 Sep 2013 Uruguay 10 Jan 2013 24 Sep 2014 Yemen 7 Jan 2014 Source: United Nations Treaty Collection web site https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IX-4- a&chapter=9&clang=_en, accessed 11 June 2021). On submitting instruments to become Party to the Protocol to Eliminate Illicit Trade in Tobacco Products, some Parties have included notes and/or declarations. All notes can be viewed at https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IX-4- a&chapter=9&clang=_en
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 205 206 | WORLD HEALTH ORGANIZATION Acknowledgements
The World Health Organization gratefully Administrative support was provided by: from ministries of finance and ministries acknowledges the contributions made to Amal Amoune-Naal, Miriamjoy Aryee- of health, and by Luk Joossens and this report by the following individuals: Quansah, Gareth Burns, Bent Elsner Konstantin Krasovsky. Jorgensen and Anne Audry Sikanda. WHO African Region: We thank Jennifer Ellis, Kelly Henning Esther Njinembo Nayeu, Nivo Marine Perraudin was responsible and Adrienne Pizatella of the Ramanandraibe, Noureiny Tcha-Kondor. for the country legislation Bloomberg Initiative to Reduce Tobacco assessment and analysis, with Use for their collaboration. WHO Region of the Americas: support from Priyanka Dahiya. Francisco Armada Perez, Adriana Our thanks also go to the WHO GIS Bacelar Gomes, Maxime Roche, Data management, data analysis and Centre for Health for providing the maps. Rosa Sandoval, Kavita Singh. creation of tables, graphs and annexes We would also like to thank Vital were performed by Alison Commar, WHO South-East Asia Region: Strategies for their advice on tobacco with support from Rula Khoury Dias and Jagdish Kaur, Arvind Rinkoo. control mass media campaigns, Soothesuk Kusumpa. Simone St Claire specifically Rebecca Perl. Special thanks WHO European Region: was responsible for the collection and also to the Campaign for Tobacco Angela Ciobanu, Elizaveta Lebedeva, coordination of the mass media data. Free Kids, especially Kaitlin Donley and Kristina Mauer-Stender. The prevalence estimates were calculated Meredith Morgan for their constructive WHO Eastern Mediterranean by Alison Commar, in collaboration with exchange of tobacco control information Region: Fatimah El-Awa, Edouard Tursan d’Espaignet. and legislation. Thanks also to Rob Sophia El-Gohary, Radwa el Wakil, Cunningham from the Canadian Cancer Data on tobacco cessation were Charles Fraser, Heba Fouad. Society for exchanging information on assessed by Dongbo Fu. WHO Western Pacific Region: health warning labels. The chapter on the Framework Melanie Aldeon, Nina Ashley dela Cruz, We thank the team from Alboum for Convention on Tobacco Control was Mina Kashiwabara, Joung-eun Lee, the quality and speed with which we drafted by Douglas Bettcher and Angela Pratt, Hai-rim Shin. received the translations of legislation, Juliette McHardy in collaboration as well as the WHO translation team WHO Country Offices: with WHO FCTC Secretariat. Many individuals in WHO Country that provides ongoing support in The chapter on Electronic Nicotine Offices contributed their time and translating the executive summaries Delivery Systems was prepared provided invaluable inputs into the in all official UN languages. with invaluable input from Indu data collection and validation process. Douglas Bettcher, Ruediger Krech and Ahluwalia, Jessica Barrington-Trimis, Vinayak Prasad reviewed the full report WHO Headquarters Geneva: Maria Carmona, Frank Chaloupka, and provided final comments. Special Rebekka Aarsand, Virginia Arnold, Robert Ekford, Karen Evans-Reeves, thanks are due to our exceptional Aikaterini Botsiou, Melanie Cowan, Stanton Glantz, Ryan Kennedy, editors Margie Peden and Angela Ranti Fayokun, Paul Garwood, Jaimie Brian King, Matt Myers, Liping Burton and our designer Optima for Guerra, Ni Jin, Kritika Khanijo, Dalia Pan, Rebecca Perl, Gan Quan. Lourenco Levin, Benn McGrady, Juliette their efficiency in helping to get this Other aspects of report were greatly McHardy, Jeremias Paul, Leanne Riley, report published on time. enriched by inputs from Anna Gilmore, Kate Robertson, Susannah Robinson, A special thanks to all tobacco focal Louis Laurence and Mateusz Zatonski Kerstin Schotte, Moira Sy. points in ministries of health for from the University of Bath. The dedicating their time to review the data COVID-19 chapter was reviewed by for their country, despite the pressures Special thanks to Adriana Blanco Silvano Gallus and his team at the Mario of the global COVID-19 situation. Marquizo, Liu Guangyuan and Kelvin Negri Institute for Pharmacological Khow Chuan Heng, WHO Framework Research in Milan, Italy. Production of this WHO document Convention on Tobacco Control has been supported by a grant from Analysis of the economics of tobacco, Secretariat, for their contributions Bloomberg Philanthropies. The including tobacco taxation and prices, to the WHO Framework Convention contents of this document are the sole were provided for this report by Anne- on Tobacco Control chapter, as well responsibility of WHO and should not Marie Perucic with support from Itziar as for their overall contributions and be regarded as reflecting the position Belausteguigoitia, Annerie Bouw, Mark comments on the draft. of Bloomberg Philanthropies. Goodchild, Roberto Iglesias and Jidapa Hebe Naomi Gouda coordinated the Sodwatana. Tax and price data were production of this report. collected with support from officials
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 207 208 | WORLD HEALTH ORGANIZATION WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 209 Photographs and illustrations
World Health Organization Page 29 – © Photographer: Tom Pictrasik Page 31 – © Photographer: Jawad Jalali Page 37 – © Photographer: Torgrim Halvari Page 38 – © Photographer: Ahmed Zouiten Page 40 – © Photographer: Yoshi Shimizu Page 49 – © Photographer: Ahmad Yusni Mohammed Said Page 57 – © Photographer: Mohamed AlArie Page 77 – © Photographer: Tanuir Murad Tapu Page 85 – © Photographer: Francisco Guerrero Page 91 – © Photographer: Sergey Volkov Page 93 – © Photographer: Sergey Volkov Page 97 – © Photographer: Arne Hoel Page 100 – © Photographer: Samy Rakotoniain Page 107 – © Photographer: Diego Rodriguez Page 108-109 – © Photographer: Sanjit Das Page 118 – © Photographer: Tami Kimelman Page 126 – © Photographer: Patrick Brown Page 138 – © Photographer: Ishaq Anis Page 152 – © Photographer: Gareth Bentley Page 178 – © Photographer: Sebastian Liste Page 192 – © Photographer: Sebastian Liste Page 198 – © Photographer: Rama George-Alleyen Page 206 – © Photographer: Samy Rakotoniain
Others Page 15 – © World Health Organization Page 17 – © Bloomberg Philanthropies Page 19 – © WHO FCTC Convention Secretariat Page 61 – © Healthy Life Style Center, Tajikistan Page 63 – © China Center for Disease Control and Prevention, China Page 67 – © Ministry of Health, Ethiopia Page 67 – © Ministry of Health, Paraguay Page 71 – © Ministry of Health, Tonga Page 71 – © WHO Country Office, Jordan Page 75 – © Ministry of Health, Mauritania Page 75 – © US Food and Drug Administration, United States of America Page 79 – © Thai Health Promotion Foundation, Bangkok, Thailand Page 84 – © Ministry of Health, Iraq Page 85 – © City of Rio de Janeiro, Brazil/Vital Strategies Page 96 – © Directorate of Medical and Health Services, Uttar Pradesh, India Page 105 – © Ukrainian Independent News and Information Agency, Ukraine Page 106 – © Ministry of Health and Welfare, National Tobacco Control Centre, Republic of Korea
210 | WORLD HEALTH ORGANIZATION The WHO report on the global tobacco epidemic, 2021 was made possible by funding from Bloomberg Philanthropies
WHO REPORT ON THE GLOBAL TOBACCO EPIDEMIC 2021 | 211 20 Avenue Appia • CH-1211 Geneva 27 • Switzerland www.who.int/tobacco