COP Out – The World Health Organization Efforts to End the Harms of Tobacco

In 2005, the World Health Organization (WHO) adopted its first treaty, the Framework Convention on Tobacco Control (FCTC), which was intended to act as an international legal agreement to apply tobacco control initiatives globally. This treaty was aimed at reducing the use of tobacco products and reducing the impact of combustible products on public health. The primary driver of establishing the FCTC was the prediction that, if allowed to continue unchecked, the number of lives lost globally per year from smoking-related disease would grow from 3.5 million lives (in 1998) to 10 million deaths per year by 2030.

The main tools the FCTC applies to the smoking problem are familiar in tobacco control spaces. These include increasing the price (through taxes and other price control measures); banning tobacco communication (advertising, promotion, etc.); mandating smoke-free spaces, including health warnings on packaging; and attempting to interrupt illicit trade activities. Currently, 181 countries have signed this treaty. Even with these efforts to reduce the number of smoking-related deaths, WHO estimated that by 2022, over 8 million people globally would die each year due to tobacco use, with the majority (80 percent) in regions considered low or middle-income countries.

The predicted global mortality rate appears to have not been significantly impacted by the FCTC. The FCTC framework excludes a promising and emerging pillar in tobacco control efforts: tobacco harm reduction (THR). The THR approach includes educating consumers on the risks of smoking and identifying and encouraging the use of reduced-risk products. Some THR policies focus on replacing smoking cigarettes with alternatives like electronic nicotine delivery systems, heated tobacco products, and smokeless tobacco products. While not risk-free, reduced-risk products have been shown to carry much less risk (up to 95 percent less) than traditional combustible products’ regular use. With the emergence of, and greater access to, reduced-risk products the death and disease associated with cigarette smoking could be mediated at a faster rate.

The Conference of the Parties (COP) is the chief mechanism for reviewing the FCTC’s actions. Every two years, the COP meets to discuss the FCTC’s effectiveness, consider additional information, and add/refine the convention’s activities. The COP includes representatives from each of the countries that have signed on to the agreement, as well as non-voting observers from countries and organizations that are not direct signatories. The COP greatly limits who may attend the meetings beyond those identified above, undertaking significant efforts to ensure that those who are not part of the FCTC working group are not able to observe, comment, or engage with any of the activities associated with the work of the delegates.

There are many opinions and arguments associated with the effectiveness of the activities associated with the FCTC, a review of which is not the purpose of this post (please review this outstanding document if you are seeking a critical review); instead, the goal is to simply summarize the actions and outcomes of the most recent COP meeting and identify any potential impact these may have on public health.

According to the FCTC website, “historic decisions” were made during COP 10. These include the adoption of Article 19, which has a primary objective of strengthening the civil and criminal regimes regarding tobacco practices; Article 18, which focused on the impact of tobacco cultivation and manufacturing on the environment; and Article 13, which limits advertising, especially in digital and social media. What is missing from the list of “successes” are agenda items that were debated (at length) with no resolutions made—Articles 10 and 9. These articles are directed toward the regulation of tobacco products and the identification of the product’s components. The central arguments were around decisions to define what constitutes a tobacco product. While there is a long history of lumping reduced-risk products into the same category of risk as combustible tobacco, several countries, led by St. Kitts and Nevis, debated the need for the FCTC to define harm reduction and proposed a working group to study the potential of a stronger integration of THR principles in the FCTC language.

Though the activities at the 10th COP meeting do not suggest any likelihood of improving the FCTC’s impact on public health, there were voices from Panama that provided a wealth of information from the science of harm reduction to effective global policy approaches, and provided a platform for consumers to debate their experiences in reducing harm. The Taxpayers Protection Alliance hosted the Good COP/Bad COP meeting in Panama the same week, providing an open forum for discussion (see all streamed events online). During the Good COP sessions, experts from across the globe discussed the negative impacts of WHO FCTC activities through scientific discussion and debate, and welcomed all viewpoints to the table.

The primary takeaway from the Good COP meetings is that in countries where THR approaches have been adopted (as compared to where the focus is wide-scale prohibition or abstinence from nicotine), public health improves. The burden on population health can be significantly reduced through easy access to reduced-risk products that consumers enjoy, completely replacing deadly combustible cigarettes. For example, in Sweden, through a combination of tobacco control approaches, education, and the availability of a culturally relevant smoking replacement, SNUS (an oral tobacco product), the rate of smoking in Sweden has dropped from over 20 percent in 2000 to less than 6 percent in 2021. The United Kingdom is also actively instituting THR principles through cigarette replacement programs offering vaping starter kits to one million smokers. The hope is that providing the starter kits will remove one of the barriers to entry for switching (the cost of vaping devices) and will support a complete transition from combustible cigarettes to a reduced-risk e-cigarette.

The aspirations of the FCTC were to reduce the impact of smoking tobacco on the health of the world’s population. After nearly two decades of advocating for the abolishment of the tobacco industry, the FCTC has had little impact in saving lives. It is time for WHO to acknowledge the existence of THR approaches and fully implement the science of THR into their strategy to improve the lives of those who smoke. Providing a supportive global environment to ensure that all communities involved receive accurate information and guidance for incorporating the best public health practices is the most efficient pathway to saving lives.