The Lancet Public Health: The global tobacco control treaty has reduced
— Despite worldwide progress since the WHO Framework Convention on Tobacco Control (WHO-FCTC) came into effect in 2005, not all key demand-reduction measures have been fully implemented at the same pace, but doing so could reduce tobacco use even further.
The global tobacco control treaty has increased the adoption of tobacco reduction measures around the world, which has led to a 2.5% reduction in global smoking rates, according to a study published in The Lancet Public Health.
The treaty obligates the 180 countries committed to it to implement strong evidence-based policies, including five key measures: high tobacco taxes, smoke-free public spaces, warning labels, comprehensive advertising bans, and support for stop smoking services. 
The study – conducted by a team of researchers from the International Tobacco Control Policy Evaluation Project, based at the University of Waterloo in Canada and the World Health Organization in Geneva – noted that although progress in combatting the global tobacco epidemic has been substantial, this progress has fallen short of the pace of global tobacco control action called for by the treaty.
One of the authors, Dr Geoffrey Fong, from the University of Waterloo, Canada, said: "The study provides strong evidence that the FCTC has led to a significant increase in the implementation of tobacco control measures. Further, the study shows that the objectives of the WHO-FCTC in reducing tobacco use can be met through adoption of key demand-reduction measures at their highest level and strong implementation of these measures. The WHO-FCTC has been a success in reducing tobacco use in countries that engaged in strong implementation and saw their smoking rates decline – at a level much greater than those countries that did not." 
The study analysed WHO data from 126 countries (116 parties and 10 non-parties), tracking strong implementation of the five key demand-reduction measures from 2007 to 2014, and examining the association between the number of measures fully implemented and country's smoking rates from 2005 to 2015.
Those countries fully implementing more of these measures experienced significantly greater reductions in smoking rates. Overall, each additional measure implemented at the highest level was associated with a reduction in smoking rates of 1.57 percentage points, which corresponds to 7.1% fewer smokers in 2015, relative to the number of smokers in 2005.
On average, smoking rates across the 126 countries went down from 24.7% in 2005 to 22.2% in 2015 – a reduction of 2.5%. However, the trends varied across countries, with smoking rates decreasing in 90 countries, increasing in 24 and remaining the same in 12 countries.
For example, from 2007 to 2014 countries in Northern Europe and South America implemented a significant number of key demand-reduction policies and experienced large reductions in smoking prevalence (7.1% and 6.8%, respectively) between 2005 and 2015. Meanwhile, countries in the African region introduced very few of these policies and experienced increases in smoking rates (3.4% in Western Africa, 12.6% in Middle Africa and 4.6% in Northern Africa).
The most frequently implemented measure by 2014 was smoke-free public places (28%, 35 of 126 countries implemented the measure, 28 of which did so between 2007 and 2014), which reduce smoking-related disease and death by protecting people from second-hand smoke and also encourage smokers to quit. The least frequently implemented measure was advertising bans (13% of countries, 16 of 126, 12 of which did so between 2007 and 2014), which have been shown to reduce the number of people starting smoking, especially among young people.
By 2014, support for stop smoking services had been adopted by 16% of countries (20 of 126) and a quarter (25.4%, 32 of 126) had implemented health warnings on cigarette packaging. A fifth of countries (22.2%, 28 of 126) had implemented high taxation on tobacco – the most effective measure for reducing smoking, especially in low- and middle-income countries where smokers are more price-sensitive.
Since the treaty came into force, a number of countries have made dramatic advances in their efforts to reduce tobacco use, including some low- and middle-income countries. Panama introduced a complete smoke-free policy and a complete ban on advertising, promotion and sponsorship in 2008, and established a strong quit assistance program in 2009. Nepal introduced a complete smoking ban and a complete tobacco marketing ban. More recently, it also introduced the world's largest pack warnings, taking up 90% of the front and back of the pack, with strong graphic images of the harms caused by cigarettes.
"While the progress of WHO Framework Convention on Tobacco Control has been remarkable, there are still far too many countries where domestication of the treaty and its implementation has fallen short," said Dr Fong. "One important cause of this is the tobacco industry's influence, particularly in low- and middle-income countries." 
According to WHO, tobacco use causes nearly six million deaths a year globally. It also poses a huge burden on the global economy through healthcare and lost productivity costs of more than US$1 trillion each year.
The study was not a fully global analysis as only 65% of countries could provide the data needed for the study, but it did include countries from all income classification levels, WHO regions and UN sub-regions.
As the study is observational the lower smoking rates could be influenced by other factors. The researchers were unable to account for how well enforced the policies were, meaning their impact could be underestimated if taking into account countries where the measure was not actually implemented properly. In addition, as many countries implement tobacco control policies together or shortly after one another, it is difficult to distinguish which measures have the largest overall impact.
"The data did not allow a detailed analysis of the impact of individual policies," said Dr Fong. "Thus, there is a need for other studies that are specifically designed to evaluate the impact of all the WHO-FCTC policies and not just the key demand-reduction measures. Such studies can provide guidance to countries about what policies may offer the greatest benefits, and can support the strong emphasis that the WHO-FCTC Conference of the Parties is placing on mobilizing efforts to accelerate and strength the implementation of the treaty." 
Writing in a linked Comment, Dr Kenneth E. Warner, University of Michigan School of Public Health, USA, said: "No study can do it all. The present undertaking is remarkably ambitious, examining, as it does, five distinct policy areas in well over 100 countries over a period spanning a decade. The authors deserve ample credit for reinforcing, with solid empirical evidence, the core message in the FCTC: tobacco control policy matters. The authors cite evidence that the FCTC has accelerated implementation of tobacco advertising, promotion and sponsorship bans, smoke-free laws, and pack warning labels. Let us hope that this study increases adoption of all of the core evidence-based demand-reduction policy interventions, especially including raising taxes, the highly effective intervention that has lagged in terms of adoption."
NOTES TO EDITORS
The study was funded by Health Canada, Canadian Institutes of Health Research and the Canadian Cancer Society. It was conducted by scientists from the University of Waterloo, University of Buffalo, the World Health Organisation and the Ontario Institute of Cancer Research.
 The study only counts the measures that have been fully implemented – for instance, to fully implement a smoke-free policy, countries must make all hospitals, schools, universities, government offices, indoor workplaces, restaurants, cafes, bars and public transport smoke-free, while to meet the standard for taxation, countries must ensure that taxes make up 75% or more of the price of a packet of cigarettes (see Figure 1).
 Quote direct from author and cannot be found in the text of the Article.
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