Policy Tag: Tobacco

Adopted by the 170th WMA Council Session, Divonne-les-Bains, France, May 2005
And amended by the 67th WMA General Assembly, Taipei, Taiwan, October 2016
And reaffirmed with minor revisions by the 218th Council session (online), London, United Kingdom, October 2021 

 

The World Medical Association: 

  1. Acknowledges the essential role of health professionals in tobacco control and urges its constituent members and other representatives of the medical community to use World No Tobacco Day each year to advocate for tobacco control measures; 
  2. Recognises the importance of the WHO Framework Convention on Tobacco Control (FCTC) as a mechanism to protect people from exposure and addiction to tobacco; 
  3. Encourages Member States to the Convention to recognize (ratify, accept, approve, confirm or accede) the Protocol to Eliminate Trade in Tobacco Products; 
  4. Encourages its constituent members to work assiduously and energetically to get their governments to implement the measures set out in the FCTC as a minimum; 
  5. In line with its Statement on Electronic Cigarettes, calls on Member States to include e-cigarettes and other electronic nicotine delivery systems in the scope of application of the WHO Framework Convention and to ensure that that these products be subjected to local regulatory approval and be entrenched in smoke free laws. 
  6. Urges governments to introduce regulations and other control measures as described in the FCTC including regulation of smokeless tobacco products. Governments should ban smoking and vaping in public places and workplaces as an urgent public health intervention and also consider additional measures, especially those tobacco control measures that have been proven to be successful in other countries; 
  7. Urges governments to introduce initiatives that break brand recognition, including plain packaging of cigarettes and other smoking products, as stated in its Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Product 
  8. Strongly encourages governments to set a distinct method to ensure adequate funding for tobacco control and research; 
  9. Urges governments to promote ready access to smoking cessation advice and services to all smokers, including children; 
  10. Recognises the vital role of health professionals in public health education and in promoting smoking cessation; 
  11. Combats the tobacco industry’s predatory marketing tactics by adopting comprehensive bans on advertising, promotion and sponsorship, as set forth in the WHO FCTC, in order to protect the health of individuals and communities; 
  12. Contributes to the improvements and updating of international tobacco control regulations as needed. 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012,
reaffirmed with minor revision by the 217th WMA Council Session (online), Seoul, South Korea, April 2021

 

The WMA reaffirms its Resolution on Implementation of the WHO Framework Convention on Tobacco Control and emphasizes the importance of this global mechanism to protect people from exposure and addiction to tobacco and tobacco products such as nicotine. 

The WMA also reaffirms its statement on e-cigarettes and the recommendation that these products be subjected to local regulatory approval and be entrenched in smoke free laws. 

The WMA recognises that : 

  • Cigarettes offer a serious threat to the life and health of individuals that use them, and a considerable cost to the health care services of every country; 
  • Those who smoke predominantly start to do so while adolescents; 
  • There is mounting evidence that e-cigarette use predicts initiation of the use of traditional tobacco products among young people and/or non-smokers, and of additional health risks from the use of e-cigarette products.
  • There is a proven link between brand recognition and likelihood of starting to smoke; 
  • Brand recognition is strongly linked to cigarette packaging; 
  • Plain packaging reduces the impact of branding, promotion and marketing of cigarettes and e-cigarette products. 

The WMA strongly encourages national governments to support the introduction of initiatives that break brand recognition, including plain packaging of cigarettes, other tobacco products, and e-cigarettes and deplores strategies from the tobacco industry to oppose the adoption and implementation of such policy. 

 

Adopted by the 63rd WMA General Assembly, Bangkok, Thailand, October 2012 and
revised by the 74th WMA General Assembly, Kigali, Rwanda, October 2023

 

PREAMBLE

Electronic cigarettes (e-cigarettes) and other electronic nicotine delivery systems (ENDS) are products designed to deliver nicotine to a user in the form of an aerosol. These products are usually composed of a mouthpiece, a rechargeable battery-operated heating element, a replaceable cartridge that contains liquid nicotine and/or other chemicals, and an atomizer that, when heated, turns the contents of the cartridge into an aerosol. This aerosol is then inhaled by the user and exhaled. These products are often made to look like other tobacco-derived products like cigarettes, cigars, pipes, toys and electronics that appeal to young people. They can also be made to look like everyday items such as pens and USB memory sticks. ENDS and their risks are outlined in more detail in the WMA Statement on Health Hazards of Tobacco Products and Tobacco- Derived Products.

Nicotine exposure, no matter how it is delivered, can affect brain development and lead to addiction. No standard definition of e-cigarettes exists, and manufacturers use different designs and different ingredients. Quality control processes used to manufacture e-cigarettes are substandard or non-existent, and few studies have been done to analyze the level of nicotine delivered to the user and the composition of the aerosol or vapor produced. Unknown amounts of nicotine are delivered to the user, and the level of absorption is unclear, leading to potentially toxic levels of nicotine in the system, especially in children, adolescents and young adults. E-cigarettes and ENDS may also contain other ingredients toxic or carcinogenic to humans including delivery solvents, propylene glycol, glycerin, pulegone, formaldehyde, acetaldehyde, acrolein, and heavy metals, such as chromium, copper, zinc, tin and lead.

Manufacturers and marketers of e-cigarettes and ENDS often claim that use of their products is a safe or safer alternative to smoking cigarettes, particularly since e-cigarettes and ENDS do not produce carcinogenic smoke. However, no studies have conclusively determined that the aerosol is not toxic or carcinogenic. There is some evidence of a risk of carcinogenicity of the respiratory tract due to long-term, cumulative exposure to nitrosamines and to acetaldehyde and formaldehyde. As with tobacco products, the safest option is to abstain from using e-cigarettes and ENDS.

Evidence already exists that e-cigarettes and ENDS are harmful and not safe.  Risks include:

  • appeal to children, adolescents and young adults, through packaging and marketing designed to appeal to these age groups, and especially when flavors like strawberry or chocolate are added to the cartridges. These factors can increase nicotine addiction among young people, and may be a gateway to experimenting with other tobacco products. Packaging and marketing targeted to young people has contributed to the dramatic increase in e-cigarette and ENDS use which in some regions is more popular than tobacco smoking.
  • the belief promoted by manufacturers that these devices are acceptable alternatives to scientifically proven cessation techniques, when neither their value as therapeutic aids for smoking cessation nor their safety as cigarette replacements is established. Evidence reveals that these products are harmful to health and not safe. In addition, evidence on the use of ENDS as a way to decrease tobacco use in adults is inconclusive;
  • inconsistent and unknown dosage, manufacturing processes, and ingredients, including the potential for abusing or manipulating the product, e.g., by adding cannabis, and simultaneous use with other tobacco products (dual or poly use);
  • high potential of toxic exposure to nicotine by children, either by ingestion or dermal absorption from contents of a nicotine cartridge, because the cartridges and refill liquids are readily available over the Internet and are not always sold in child resistant packaging;
  • worse clinical outcomes in patients with the SARS-COV2 virus who also use e-cigarettes.

 

RECOMMENDATIONS

  1. That e-cigarettes and ENDS be subject to the WHO Framework Convention on Tobacco Control, and to jurisdictional smoke-free laws and regulations.
  2. That the manufacture and sale of e-cigarettes and ENDS be subject to national regulatory bodies as either a new form of tobacco product or as a drug delivery device. At a minimum, regulations should address maximum strength of nicotine fluids, tank size on vaping devices, product labeling, and child-resistant packaging. This recommendation also applies to devices using synthetic nicotine.
  3. That clinical testing, large population studies and full analyses of e-cigarette ingredients and manufacturing processes be conducted to determine their level of risk, viability, and efficacy as tools for tobacco cessation.
  4. That e-cigarettes and other ENDS should never be marketed as a valid or efficacious method for smoking cessation without validated clinical research that is assessed by appropriate regulatory bodies. In all other instances, plain package marketing should be required, in accordance with the WMA Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Product.
  5. That the sale, marketing, distribution, and accessibility of e-cigarettes and other tobacco products to children and adolescents be prohibited.
  6. That the production, distribution and sale of flavored e-cigarette cartridges and candy products that depict or resemble tobacco products be prohibited.
  7. That the sale of e-cigarettes and ENDS via the internet be prohibited in order to prevent access to these products by minors.
  8. That physicians, pediatric practitioners and dentists inform their patients of the potential risks of using e-cigarettes and ENDS, e.g., addiction, cardiovascular disease, lung disease, impact on brain development due to nicotine, physical injuries, etc., even if regulatory authorities have not taken a position on the efficacy and safety of these products.
  9. That the WMA and its members support further research on the harmful effects of e-cigarettes and ENDS, especially in children, adolescents and young adults.

Adopted by the 40th World Medical Assembly, Vienna, Austria, September 1988
Revised by the 49th WMA General Assembly, Hamburg, Germany, November 1997,
the 58th WMA General Assembly, Copenhagen, Denmark, October 2007,
the 62nd WMA General Assembly, Montevideo, Uruguay, October 2011
and the 73rd WMA General Assembly, Berlin, Germany, October 2022

 

PREAMBLE

Over 80 percent of the world’s 1.3 billion smokers live in low- and middle-income countries. Smoking and other forms of tobacco use adversely affect every organ system in the body, and are major causes of cancer, heart disease, stroke, chronic obstructive pulmonary disease, fetal damage, and many other conditions. Smokers have up to a 50% higher risk of developing severe disease and death from COVID-19. Eight million deaths occur worldwide each year due to tobacco and tobacco- derived products. Tobacco will kill one billion people in the 21st century unless effective interventions are implemented.

Exposure to secondhand smoke occurs anywhere the burning of tobacco products occurs in enclosed spaces. There is no safe exposure level to secondhand smoke, which causes millions of deaths each year. It is especially damaging to children and pregnant patients. On May 29, 2007, the WHO called for a global ban on smoking at work and in enclosed public places to eliminate secondhand smoke and encourage people to quit.

The phenomenon known as “thirdhand smoke” occurs when nicotine and other chemical residues occur on indoor surfaces from smoking, which can persist long after the smoke itself has cleared. It is increasingly recognized as a potential danger, especially to children, who not only inhale fumes released by these residues but also ingest residues that get on their hands after crawling on floors or touching walls and furniture.

World Health Organization Action

With the hope of mitigating the effects of tobacco use, the World Health Organization (WHO) Member States unanimously adopted the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003. In force since 2005, it currently has 182 parties covering more than 90 percent of the world’s population. Further strengthening implementation of the milestone treaty is specifically included in the 2030 Agenda for Sustainable Development Goals (SDG) as Target 3.a. The WMA has long supported the WHO FCTC (see WMA Resolution on Implementation of the WHO Framework Convention on Tobacco Control). The Protocol to Eliminate Illicit Trade in Tobacco Products, the first protocol to the WHO FCTC, was adopted in 2012 in response to the growing international illicit trade in tobacco products. The objective of the Protocol is the elimination of all forms of illicit trade in tobacco products, in accordance with the terms of Article 15 of the WHO FCTC.

 New and Emerging Nicotine Products

 The WMA Statement on Electronic Cigarettes and Other Electronic Nicotine Delivery Systems outlines the still-unknown risks associated with these products.  The use of e-cigarettes by young people has risen dramatically, and in some regions is more popular than tobacco smoking.  Nicotine exposure, no matter how it is delivered, can affect brain development and lead to addiction.

New and rediscovered forms of tobacco and nicotine ingestion are also emerging, including:

  • dissolvable tobacco, from sweet, candy-like lozenges that contain tobacco and nicotine that are held in the mouth, chewed, or sucked until they dissolve;
  • snus, a finely ground form of moist snuff that that contains carcinogens and is usually packaged in small pouches;
  • hookahs, a water pipe that burns tobacco mixed with flavors such as honey, molasses or fruit, where the smoke is inhaled through a long hose. The WHO reports that one hookah smoking session is the same as smoking 100 cigarettes, largely due to the length of time a user smokes;
  • bidis, flavored cigarettes that are unfiltered and deliver up to five times more nicotine than regular cigarettes, and clove cigarettes (also called Kreteks) also deliver more nicotine, carbon monoxide, and tar than regular cigarettes;
  • other heated tobacco products that typically use an electronic heating element to heat specially designed sticks, plugs, or capsules containing tobacco. The heat releases nicotine (and other chemicals) that can then be inhaled into the lungs, but the tobacco does not get hot enough to burn. These devices are not the same as e-cigarettes, and
  • Nicotine pouches, tobacco free pouches of nicotine with different flavors which are placed in the mouth.

Pregnant Patients and Children

Smoking or using nicotine during pregnancy is linked with a range of poor birth outcomes including low birth weight and preterm birth, restricted head growth, placental problems, increased risk of still birth and increased risk of miscarriage. Breathing secondhand smoke during pregnancy also increases the risk of having a low-birth-weight baby, and babies who are exposed to secondhand smoke have an increased risk of Sudden Infant Death Syndrome.

Health and developmental consequences among children have also been linked to prenatal smoke exposure, including poorer lung function, (including coughs, colds, bronchitis and pneumonia), persistent wheezing, asthma and visual difficulties such as strabismus, refractive errors and retinopathy. Children who breathe more secondhand smoke have more ear infections, coughs, colds, bronchitis and pneumonia. Children who grow up with parents who smoke are themselves more likely to smoke and to have long term health effects similar to adults who smoke.

Health Equity

Health equity in tobacco prevention and control focuses on the opportunity for all people to live a healthy life, regardless of their race, level of education, gender identity, sexual orientation, occupation, geographic location, or disability status. Tobacco control programs, including evidence-based cessation services, can work toward health equity by focusing efforts on decreasing the prevalence of tobacco use, and second-hand and thirdhand smoke exposure, and by improving access to tobacco control resources, among populations experiencing greater tobacco-related health and economic burdens.

Tobacco Industry Marketing

 The tobacco industry spends billions of dollars annually around the globe on advertising, promotion and sponsorship. The tobacco industry’s manipulative and predatory marketing tactics increase consumption of its products and replace smokers who quit or die. By investing huge sums of money in low- and middle-income countries, the industry hopes to increase the social acceptability of tobacco and tobacco companies. The tobacco industry has also long employed strategies targeting children, from developing special packaging or candy-flavored cigarettes and e-cigarette cartridges, and has used the internet, text messaging and youth-oriented social networking sites to advertise sponsored events or promotions.

The best strategy to combat the tobacco industry’s marketing tactics is to adopt and enforce comprehensive bans on tobacco advertising, promotion and sponsorship, as set forth in the WHO FCTC.

The tobacco industry claims that it is committed to determining the scientific truth about the health effects of tobacco, both by conducting internal research and by funding external research through jointly funded industry programs. However, the industry has consistently denied, withheld, and suppressed information concerning the deleterious effects of tobacco smoking.

Tobacco companies also manipulate the public’s attitude about their reputation and have often engaged in so-called ‘corporate social responsibility’, which are activities to promote their products while portraying themselves as good corporate citizens.

 

RECOMMENDATIONS

The WMA recommends that national governments:

  1. Increase taxation of tobacco and tobacco-derived products, which is the single most effective tobacco control measure to reduce tobacco use according to the World Health Organization (WHO). Taxation is also a highly cost-effective and inexpensive tool. Increased revenues should be used for prevention programs, evidence-based cessation programs and services, and other health care measures.
  2. Urge the WHO to add tobacco cessation medications with established efficacy to the WHO’s Model List of Essential Medicines.
  3. Ratify and fully implement the WHO Framework Convention on Tobacco Control.
  4. Implement comprehensive regulation of the manufacture, sale, distribution, and promotion of tobacco and tobacco-derived products, including total bans on tobacco advertising, promotion and partnership, including abroad. Require plain packaging of tobacco products (as set forth in the WMA Resolution on Plain Packaging of Cigarettes, e-Cigarettes and Other Smoking Products), and packaging that includes prominent written and pictorial warnings about health hazards of tobacco.
  5. Prohibit smoking in all enclosed public places, including public transportation, prisons, airports and on airplanes. Require all medical schools, biomedical research institutions, hospitals, and other health care facilities to prohibit smoking, and the use of smokeless tobacco and other tobacco-derived products on their premises.
  6. Prohibit the sale, distribution, and accessibility of cigarettes and other tobacco products to children and adolescents. Ban the production, distribution and sale of candy products that depict or resemble tobacco products.
  7. Prohibit all government subsidies for tobacco and tobacco-derived products and assist tobacco farmers in switching to alternative crops. Exclude tobacco products from international trade agreements, and work to curtail or eliminate illegal trade in tobacco and tobacco-derived products and the sale of smuggled tobacco products.
  8. Provide for research into the prevalence of tobacco use and the effects of tobacco and tobacco-derived products on the health status of the population.

The WMA recommends that national medical associations:

  1. Refuse funding or educational materials from the tobacco industry, and urge medical schools, research institutions, and individual researchers to do the same.
  2. Adopt policies opposing smoking and the use of tobacco and tobacco-derived products and publicize the policy. Endorse or promote clinical practice guidelines on the treatment of tobacco use and dependence.
  3. Prohibit smoking, including use of smokeless tobacco and vaping, in national medical association premises and at all business, social, scientific, and ceremonial meetings of national medical associations, in line with the decision of the World Medical Association to impose a similar ban.
  4. Develop, support, and participate in programs to educate the profession and the public about the health hazards of tobacco use (including addiction) and exposure to secondhand smoke.
  5. Introduce or strengthen educational programs for medical students and physicians to prepare them to identify and treat tobacco dependence in their patients.
  6. Speak out against the shift in focus of tobacco marketing from developed to less developed nations, from adults to youth, and urge national governments to do the same.
  7. End investment in companies or firms producing or promoting the use or sale of tobacco or tobacco-derived products. Divest current assets that support tobacco production or promotion.

The WMA recommends that physicians:

  1. Be positive role models by not using tobacco or tobacco-derived products, and by acting as spokespersons to educate and raise the awareness of the public about the deleterious health effects of tobacco use and the benefits of tobacco-use cessation.
  2. Support widespread access to evidence-based treatment for tobacco dependence through individual patient encounters, counseling, pharmacotherapy, cessation classes, telephone quit-lines, web-based cessation services, and other appropriate means.
  3. Recognize that tobacco and second-hand smoke exposure to adult tobacco use cause harm to children. Special efforts should be made by physicians to:
  • promote tobacco-free environments for children
  • target parents and pregnant patients who smoke for tobacco cessation interventions
  • promote programs that contribute to the prevention and decreased use of tobacco and tobacco-derived products by youth
  • support policies that control access to and marketing of tobacco and tobacco-derived products and make pediatric tobacco-control research a higher priority.