12 96
3.6.2.
The
need
for
comprehensiveness
in
tobacco
control
policies
Tobacco
control
policies
need
to
be
comprehensive
and
include
all
tobacco
products. Otherwise,
smokers may
just
substitute
one product
for
another.
In
Poland,
for
example,
following
a
cigarette
excise
tax
increase
in
January
2004,
sales
of
manufactured
cigarettes
declined
while
sales
of
tobacco
for
RYO
cigarettes
increased
(from
a
cigarette
equivalent
of
3.4
billion
in
2003
to
5.7
billion
in
2004).
When
tax
rates were
increased
on
both manufactured
and
RYO cigarettes
in
January 2005, pipe
tobacco sales
increased
from
a
cigarette
equivalent
of
0.2
billion
in
2004
to
2.0
billion
in
2005
and
3.3
billion
in
2006
[99] .3.6.3.
Lobbying
and
litigation
More
than
85%
of
all
cigarettes
smoked
globally
are
being
produced
by
only
six
transnational
companies:
China
National
Tobacco
Corporation,
Philip Morris
International,
British
American
Tobacco,
Japan
Tobacco
International,
Imperial
Tobacco
Group,
and
Altria
Group
[63].
Each
of
these
companies has
a
gross
revenue
that
is
comparable
to
the
gross
domestic
product
of
a
small
country
[2].
These
companies
frequently
lobby
or
challenge
tobacco
control
proposals
legally
to
block
or
delay
their
implementation.
Examples
include
a multimillion-dollar
lobbying
campaign
to
undermine
the
revision
of
the
EU
Tobacco
Products
Directive
[100]and
a
challenge
to
Australia’s
plain
packaging
regulations
in
domestic
courts,
at
the
World
Trade Organization,
and
in
international
arbitration
as part
of
a
bilateral
investment
treaty
[101,102].
In
contrast,
governments,
health
organizations,
and
individuals
in
several
countries
have
sued
the
tobacco
industry
for
violating
tobacco
control
regulations
and
for
the
health
and
environmental
consequences
of
their
products
and
practices
[103,104] .3.7.
Regulating
e-cigarettes
How
to
regulate
e-cigarettes
is
a
matter
for
debate
and
research.
Regulatory
objectives
for
e-cigarettes
recom-
mended
by WHO
include
impeding
ENDS
promotion
to
and
uptake
by
nonsmokers,
pregnant women,
and
youth;
minimizing
potential
health
risks
to
ENDS
users
and
nonusers;
prohibiting
unproven
health
claims
from
being
made
about
ENDS;
and
protecting
existing
tobacco
control
efforts
from
commercial
and
other
vested
interests
of
the
tobacco
industry
[105] .Some authorities have already taken
steps
to
regulate
e-cigarettes.
For
example,
within
the
provisions of
the
revised EU Tobacco Products Directive,
the
amount of nicotine
in
e-cigarettes
and
refill
containers will
be
limited,
products
will
be
required
to
carry
health
warnings,
and
e-cigarette
advertising
will
be
banned
(unless
approved
for
advertising
as
a
smoking
cessation
device)
in all 28 EU member
states by May 2016
[86] .In
the
United
States,
in
contrast,
the US
Food
and Drug Adminis-
tration
(FDA) now has no authority
to
regulate e-cigarettes.
Although
the
FDA
proposed
a
new
rule
in
April
2014
to
extend
its
authority
to
e-cigarettes,
including
some
basic
measures
such
as bans on
e-cigarette
sales
to minors or on
the
distribution
of
free
samples,
implementation
of
any
regulation of e-cigarettes,
if adopted, may
take several years
[106].
3.8.
Investing
in
tobacco
control
Few
public
health
investments
provide
greater
dividends
than
tobacco
control. Countries
that have
implemented
the
best practices reflected
in
theWHO FCTC are now benefiting
from
their
actions.
For
example,
since
1989,
Brazil
has
reduced
its
smoking
rates
by
close
to
half
through
several
tobacco
control
initiatives.
It
is
estimated
that
those
combined
policies
averted
420
000
deaths
by
2010, more
than
half
of which were
because
of
cigarette
tax
increases
[107].
The
comprehensive
tobacco
control
policies
that
were
implemented
globally
from
2007
to
2010
alone
prevented an estimated 7.5 million
smoking-related deaths
[108].
Tobacco
control
interventions
are
relatively
inexpensive
to
implement. WHO
estimates
that delivering
four popula-
tion-based
tobacco control measures
(tobacco
tax
increases,
smoke-free
policies,
package
warnings,
and
advertising
bans)
to all LMICs would cost only $600 million, or $0.11 per
person,
annually.
This
amount
includes
the
human
resources
and
physical
capital
needed
to
plan,
develop,
implement, monitor,
and
enforce
the
policies
[109].
Cur-
rently,
only
$0.02
per
person
is
spent
annually
on
tobacco
control
in
LMICs
[110] .Several
tobacco
control
interven-
tions have even proven
to be
cost
saving, which means
that
for
every
dollar
spent
on
these
interventions
there
was
more
than one dollar yielded
in
return
in
saved health
care
costs
and
human
productivity
[111,112] .3.9.
Limitations
Data
from
national
surveys
were
not
available
for
all
countries;
or
when
available,
the
data
might
not
be
comparable
in
some
cases
because
they
were
collected
using
different methodologies
or
in
different
years, which
might
not
reflect
recent
changes
in
smoking
prevalence
or
tobacco
control
policies.
Despite
these
limitations,
the
availability
of
data
from
several
countries
in
each
region
would
be
sufficient
to
illustrate
the
smoking
prevalence,
trends,
and
tobacco
control
policies
in
all
regions.
4.
Conclusions
Smoking
prevalence
is
decreasing
globally
because
of
heightened awareness about
the health hazards of
smoking
and
the
implementation
of
effective
tobacco
control
policies.
However,
smoking
is
still
a
common
habit,
particularly
in
Asia,
Eastern
Europe,
southern
Europe,
and
a
number
of
other
LMICs.
Additionally,
rapid
population
growth
and
the
expected
increase
in
smoking
prevalence
because
of
the
adoption
of Western
lifestyles
associated
with economic development and urbanization could
lead
to
many more
smokers
and
tobacco-related
diseases
in
parts
of Africa
and
Latin America. Governments,
in
collaboration
with
the broader society, must
implement effective
tobacco
control policies where
they are
lacking. Particular attention
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