Policy Tag: Tobacco Control

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 200th WMA Council Session, Oslo, April 2015,
and adopted, with amendments by the 72nd WMA General Assembly (online), London, United Kingdom, October 2021 

 

PREAMBLE

Trade agreements are treaties between two or more countries which include provisions addressing trade in goods and/or services. Trade agreements are tools of globalization and typically seek to promote global wealth through trade liberalization. They can have significant implications for the social, commercial, political and ecological determinants of health as well as the delivery of health care. 

International trade contributes significantly to increases in national wealth which is a key factor in building strong health care systems.  

While trade agreements are designed to produce economic benefits and global wealth, it is fundamental to identify public health implications that may arise from these agreements.  

Negotiations should take into account broad impact to ensure that the right to health and to a healthy natural and social environment are well-prioritized. Trade agreements should be directed at contributing to global health and equity. 

Trade agreements may have the ability to promote the health and wellbeing of all people when they are well-designed to protect health and preserve the ability of governments to legislate, regulate and plan for health promotion, health care delivery and health equity. 

Recent trade agreement negotiations have sought to establish a new global governance framework for trade and have been unprecedented in their size, scope and secrecy. A lack of transparency and the selective sharing of information with a limited set of stakeholders are anti-democratic. 

There must be recognition of the importance of innovation sharing in public health. This is particularly important during health emergencies. Access to medicines and medical supplies is essential to address the major public health problems such as pandemics and trade agreements must not act as a barrier to that access. 

Investor-state dispute settlement (ISDS) provides a mechanism for investors to bring claims against governments and seek compensation, operating outside existing systems of accountability and transparency. ISDS in existing trade agreements has been used to challenge evidence-based public health measures including tobacco plain packaging. Inclusion of a broad ISDS mechanism could threaten public health actions designed to support evidence-based tobacco control, alcohol control, healthy and safe food consumption including regulation of obesogenic foods and beverages, access to medicines, health care services, environmental protection/climate change and occupational / environmental health protections. Efforts by industry to challenge domestic public health laws and regulation have targeted nations with limited access to legal resources and some of the world’s most vulnerable populations. 

Access to affordable medicines is critical to controlling the global burdens of communicable and non-communicable diseases. The World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) established a set of common international rules governing the protection of intellectual property including the patenting of pharmaceuticals. TRIPS safeguards and flexibilities including compulsory licensing seek to ensure that patent protection does not supersede public health. 

The WMA Statement on Patenting Medical Procedures states that patenting of diagnostic, therapeutic and surgical techniques is unethical and “poses serious risks to the effective practice of medicine by potentially limiting the availability of new procedures to patients.” 

Trade agreements should not pose a new difficulty in accessing medicines, especially for developing countries and for the most vulnerable populations. 

There must be a fair balance established between the prices of medicines and the protection of intellectual property through patents. 

The WMA considers that patenting on medicines/vaccines must be regulated in accordance with the ethical principles and values of the medical profession in order to ensure effective and global action for public health and therefore recognizes that it may be necessary to temporarily waive patents in times of public health emergencies.  Moreover, to produce fast and comprehensive results, sustainable solutions for patent issues must be supplemented by the transfer of technology, knowledge, and manufacturing expertise, global investment in manufacturing sites, training of personnel, and quality control. 

The WMA Resolution on Medical Workforce states that the WMA has recognized the need for investment in medical education and has called on governments to “…allocate sufficient financial resources for the education, training, development, recruitment and retention of physicians to meet the medical needs of the entire population…” 

The WMA Declaration of Delhi on Health and Climate Change states that global climate change has had and will continue to have serious consequences for health and demands comprehensive action. 

The WMA Declaration on Fair Trade in Medical Products and Devices states that purchasing policies for medical goods should be fair and ethical, working conditions should be safe and modern slavery should be eradicated throughout supply chains. Health product manufacturers should establish a plan for continuity of supply of vital and life-sustaining products to avoid production shortages whenever possible. This plan should include establishing the necessary resiliency and redundancy in manufacturing capability to minimize disruptions of supplies. 

 

RECOMMENDATIONS 

 Therefore, the WMA calls on national governments and constituent member associations to: 

1.Call for transparency and openness in all trade agreement negotiations including public access to negotiating texts and meaningful opportunities for stakeholder engagement. 

2. Call for a proactive assessment of anticipated effects on health, human rights, and the environment for all trade agreements. 

3. Advocate for trade agreements that protect, promote and prioritize public health over commercial or political interests, and secure services in the public interest, especially those affecting individual and public health. This should include new modalities of health care provision including eHealth. 

4. Ensure that trade agreements do not have negative impacts on health systems, human resources for health and universal health coverage (UHC). Ensure trade agreements do not interfere with governments’ ability to protect and regulate health and health care, or to guarantee a right to health for all. Government action to protect and promote health should not be subject to challenge through an investor-state dispute settlement (ISDS) or similar mechanism.

5. Work to ensure that patents on medicines and vaccines are regulated in accordance with the principles of medical ethics, in order to protect public health in global emergency situations.  

6. Therefore, urge NMAs to promote the possibility of temporarily waiving patents on medicines and vaccines to protect public health in global emergency situations while ensuring fair compensation for the intellectual property of the patent holders, global investment in manufacturing sites, and knowledge transfer. Promote public health, equity, solidarity and social justice and protect countries and people who are weaker economically and health-wise, and therefore most vulnerable. 

7. Oppose any trade agreement provisions which would compromise access to health care services or medicines including but not limited to: 

  • Patenting (or patent enforcement) of diagnostic, therapeutic and surgical techniques; 
  • “Evergreening”, or patent protection for minor modifications of existing drugs; 
  • Patent linkage or other patent term adjustments that serve as a barrier to generic entry into the market; 
  • Data exclusivity for biologics; 
  • Any effort to undermine TRIPS safeguards or restrict TRIPS flexibilities including compulsory licensing; 
  • Limits on clinical trial data transparency. 

8. Oppose any trade agreement provision which would reduce public support for or facilitate commercialization of medical education. 

9. Oppose any trade agreement which would facilitate the inappropriate privatization of public services in areas such as conservation of natural environment, education, healthcare, and daily necessities such as energy and water. 

10. Ensure that trade agreements promote environmental protection and support efforts to reduce activities that cause climate change. 

 11. Ensure that trade agreements promote equity and human rights and include mechanisms for accountability following implementation. 

 

 

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.