Show me the Evidence

Srping 2012
Volume 1, Issue 2

[ Table of Contents ]

CIHR-Funded Project Helps Nations Compare and Improve Their Tobacco-Control Policies

University of Waterloo professor leads the 23-country project

At a Glance

Who: Dr. Geoffrey Fong, University of Waterloo.

Issue: Tobacco use is a major risk factor in deaths caused by non-communicable diseases (NCDs). Worldwide, 63% of deaths are caused by NCDs. Exposure to second-hand smoke kills 600,000 people each year.1

Project: With CIHR funding, Dr. Fong founded the ITC Project in 2002 to conduct international cohort studies of tobacco use and measure the impacts of the World Health Organization’s Framework Convention on Tobacco Control. The ITC Project has produced eight national reports since 2008, as well as two policy reports and 13 summaries in nine countries. Currently 23 countries are active participants.2

Research Evidence: The ITC Project has provided evidence that policies in some countries are not effective. For example, in China the project demonstrated that three critical policies – warning labels, smoke-free laws and taxation – have had virtually no effect because of poor implementation.

Evidence in Action: ITC National Reports play a critical role in presenting and evaluating a given country's role in tobacco regulation. Policy makers use the ITC reports in shaping efforts at tobacco control.

Sources: The impact of pictures on the effectiveness of tobacco warnings, Bulletin of the World Health Organization 87, 8 (August 2009): 640–643.

As one of the world’s leading tobacco-control experts, the University of Waterloo’s Dr. Geoffrey Fong is in a position any researcher would envy: When he speaks, government leaders listen.

In the foreword to the France National Report by Dr. Fong's International Tobacco Control Evaluation Project (ITC Project), Xavier Bertrand, French Minister of Labour, Employment and Health, expresses gratitude for the "invaluable evidence to guide us in our efforts to fight the number one preventable cause of death and illness in the world."

Minister Bertrand's words, published in late 2011, echo those of Dr. A. F. M. Ruhal Haque, Bangladesh's Minister of Health and Family Welfare, writing that the ITC National Report on his country reveals that "much still needs to be done to reduce tobacco use and to prevent the future health, social and economic consequences of tobacco use." ITC's findings, he says, "will inspire us to do more."

The ITC National Reports, produced in part with CIHR funding, are the brainchild of Dr. Fong, who founded the ITC Project with colleagues in four countries in 2002 and has built it into a powerful 23-nation initiative. The reports represent a major way in which the ITC Project fulfills its mission of measuring the psychosocial and behavioural impacts of the World Health Organization's (WHO) 2003 Framework Convention on Tobacco Control (FCTC).

By conducting parallel surveys in countries representing 60% of the world's smokers, the ITC Project keeps participating nations informed about the effects of implementing tobacco-control policies such as graphic warning labels and smoke-free laws. Just as significantly, the reports and summaries tell leaders and policy makers how their country is doing compared to other jurisdictions.

"It's very important to get our findings out in ways that are understandable and clear," says Dr. Fong, a professor of psychology and Senior Investigator at the Ontario Institute for Cancer Research. "The reports focus on ITC findings that indicate where a country stands in respect to threat of tobacco use and whether its tobacco policies are working. If they are not working, then the ITC findings constitute evidence that we hope will give policy makers the courage to do what's right."

Doing what's right is often difficult when it comes to tobacco control. While tobacco use is blamed for more than 5 million deaths a year3 and could kill 1 billion people in this century,4 the tobacco lobby is richly funded and many countries' economies are bolstered by jobs produced by the industry and taxes collected from it.

To counterbalance those forces, the ITC Project provides tobacco-control advocates with evidence to press their governments to take action, says Deborah Arnott, Chief Executive of the United Kingdom's Action on Smoking & Health (ASH). Again, the fact that the evidence spans several countries gives it additional weight.

A hand holding a cigarette package with the message: Policy makers use the ITC reports in shaping efforts at tobacco control

Evidence in Action: Findings Key to Tobacco-Control Policy Decisions

ITC National Reports play a critical role in presenting and evaluating a given country's role in tobacco regulation. So far, the ITC has produced nine national reports, and the work has earned high praise from policy makers, who consider the reports critical to their efforts at tobacco control. In the foreword to the France National Report by Dr. Fong's International Tobacco Control Evaluation Project, Xavier Bertrand, French Minister of Labour, Employment and Health, expresses gratitude for the "invaluable evidence to guide us in our efforts to fight the number one preventable cause of death and illness in the world."

"The UK does a lot of good research on what happens in the UK," says Ms. Arnott, "but what ITC Project does – which adds great value – is comparable research, looking at how the UK compares to other countries. We know, for example, that Canada is in advance of us in a lot of areas of tobacco control. For example, health warnings. Canada has had health warnings (on cigarette packs) in place longer than we have and has graphic warnings in place. It helps in the argument to get graphic warnings here."

The ITC has also provided evidence that policies in some countries are not effective. For example, in China the ITC Project has demonstrated that three critical policies – warning labels, smoke-free laws and taxation – have had virtually no effect because of poor implementation. In May 2009, the Chinese government raised tobacco taxes in accordance with their obligations under the FCTC. However, to date, prices have not increased, so there has been no impact on reducing tobacco use. Also, the government issued larger warning labels on both sides of the pack in 2008, but printed the warning on the back of the pack in English.

The ITC Project has also called attention to ineffective policies in the Netherlands. "We saw ourselves as very advanced in tobacco control," says professor Marc Willemsen of Maastricht University's School for Public Health and Primary Care, "because we have spent quite a few Euros on smoking cessation campaigns. It was shocking to find out Dutch smokers were lagging in awareness of health risks compared to most other ITC countries."

Professor Willemsen says the ITC findings have "helped us look differently at the whole problem of tackling tobacco in the Netherlands. It was instrumental in putting tobacco control on the agenda of the Dutch Cancer Foundation. They are now planning a mass media campaign for awareness of the health consequences of smoking. This all came from ITC data."

The globetrotting Dr. Fong also takes the ITC research directly to policy makers and politicians, recently appearing before British Parliamentarians who were preparing a report on whether smoking in cars in which children are passengers should be banned.

"He was able to tell them about the levels of support from smokers in Canada and how that compared to support among smokers in the UK," says Ms. Arnott. That went in the cross-party report, which has been sent to the Minister of Health and the Prime Minister. His presentation was absolutely essential to getting Parliamentarians to believe that this is something we should be taking action on."

World Health Organization Considers ITC Project Essential to Its Efforts

The ITC Project's research is vital to the World Health Organization's initiative to reduce smoking around the world, says Dr. Douglas Bettcher, the Geneva-based Director of the organization's Tobacco Free Initiative. "The ITC Project, initiated by Dr. Fong, provides timely evidence and inspiration to countries committed to effective implementation of the World Health Organization FCTC. I am looking forward to his ongoing contribution towards a tobacco-free world."

CIHR was one of the earliest supporters of Dr. Fong's ambitious ITC Project when it began in 2002. "It has been extraordinary in supporting the international work," says Dr. Fong. "Thanks to CIHR we've had funding since 2009 to produce our national reports." More recently, Dr. Fong's team was awarded $7.4 million – the largest operating grant ever issued by CIHR – to carry on the ITC Project's work in evaluating the impact of the FCTC, especially in low- and middle-income countries.


  1. WHO Tobacco Free Initiative
  2. Email correspondence Nov. 17, 2011, with Dr. Lorraine V. Craig, ITC Europe Project Manager and Dissemination Manager.
  3. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2009: Implementing smoke-free environments. Geneva, 2009.
  4. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. Geneva, 2008.