Going Global in the Fight against Tobacco

When it comes to tobacco use, society has a long way to go, baby. Smoking is still the number one preventable cause of death in Canada, and the situation worldwide is far worse: an estimated 1 billion people will die of tobacco-related illnesses during the 21st Century.

In response to this health crisis, the World Health Organization (WHO) established the Framework Convention on Tobacco Control (FCTC). More than 160 countries have ratified this global treaty and pledged to introduce anti-tobacco policies, such as graphic warning labels on cigarette packages and higher taxes on tobacco products.

Dr. Geoffrey Fong, a Canadian Institutes of Health Research (CIHR)-funded researcher at the University of Waterloo, is leading the International Tobacco Control Policy Evaluation Project (the ITC Project), which is assessing the real-world impact of the FCTC's policies in 19 countries inhabited by more than 70% of the world's tobacco users. In the following Q&A, Dr. Fong shares some of his thoughts on the challenges of reducing tobacco use around the world.

Question: Most people are aware that smoking is harmful, yet people still smoke. What are some of the strategies that tobacco companies use to hook new smokers?

Answer: Even though Canadian laws prohibit most types of tobacco advertising, tobacco companies still find ways to promote their products. For example, companies can still run print ads in publications aimed primarily at adults. The majority of the world's smokers live in the developing world, where overt tobacco advertising is allowed and the public is less aware of the harms of smoking. In China, there are more than 300 million smokers, and only 25% have any plans to quit, whereas more than 80% of Canadian smokers plan to quit.

Question: What are the major obstacles to creating effective tobacco control policies?

Answer: The tobacco industry itself is probably the biggest obstacle. We can't think about tobacco the same way we would about HIV or cholera. The tobacco industry has had tremendous influence in so many areas of our society. In some countries this influence is very overt, such as in China, where the tobacco industry is owned by the government. In other countries, like Canada, tobacco companies have used more subtle tactics, such as corporate sponsorships that attach companies' names to artistic and cultural events. A second problem is that the tobacco industry has been involved in decades of misinformation about the harms of smoking. Initially they tried to cast doubt on the scientific evidence that smoking could cause cancer, then they introduced terms like "light" and "low-tar" to reassure health-concerned smokers that there were lower-harm alternatives. In reality, low tar and mild cigarettes confer no health benefits whatsoever, but they keep smokers in the game. A third barrier in Canada is that many people believe the tobacco problem has been solved. But close to 20% of Canadians smoke and it is still the leading preventable cause of death among Canadians.

Question: How can you tell if a tobacco control policy is working?

Answer: We can't randomly assign people to policies in our studies, so we use "quasi-experimental" designs, also known as natural experiments. For example, to evaluate the effect of graphic warnings in Thailand, we surveyed more than 1,500 Thai smokers before the introduction of the new labels. Then, about 16 months after the graphic warning labels were introduced, we surveyed those same smokers again. We found a significant increase in all the key measures of warning label impact, including reports that the labels were a source of information about the health risks of smoking, reports that smokers saw the labels as a motivation to quit, and perhaps most importantly—since we have found this to be significantly related to later quitting—an increase in reports that the warning labels made smokers forego a cigarette they were about to smoke. We compared these results to Malaysia—which had not introduced new labels, and thus served as a natural "control" country. We found there was no similar favourable change in these key measures in Malaysia.

Question: What do you do with the results of your studies?

Answer: One of our main objectives is to get our information out to not only the scientific community, but also to policy makers all over the world. The ITC Project is currently the only international project that is evaluating the FCTC policies at the population level anywhere in the world. So our evidence has been of great interest as the FCTC parties negotiate and create the guidelines and protocols for the treaty. In November, I was in Durban, South Africa, at the annual gathering of the FCTC parties—called the Conference of the Parties. The South Korean delegates announced that they were unsure whether they would support graphic warnings because they believed that the labels might make smokers depressed. The FCTC Secretariat asked me to talk to the South Korean delegates about the supporting research evidence, and I was able to cite ITC Survey data from their own country. The next day, the South Korean delegation announced that they were now fully supportive of graphic warnings.

Question: What can we learn from international collaborations like the ITC Project that we cannot learn from smaller studies?

Answer: In each of our 19 countries, the ITC Survey has either identical or very similar questions about tobacco use. Having common measures all based on a common conceptual model allows us to make stronger and more appropriate comparisons across countries, especially comparisons about the impact of policies or variations in policies across different countries. We are finding that pictorial warnings are superior to text warnings. And we are finding that comprehensive smoke-free laws are working well in nearly all countries. These broader, country-level conclusions are not possible in smaller studies.

Question: What could Canada do to improve its own tobacco control policies?

Answer: Canada has been seen throughout the world as a leader in tobacco control. The graphic warning labels we introduced in 2001 have been an inspiration to many other countries. We must continue to revise and update those labels based on solid research. Canada also needs to close the loopholes in our advertising laws so that the Canadian public is no longer subjected to ads from tobacco companies.