Tobacco is the most prevalent cause of premature morbidity and mortality in the world, with an estimated one billion people predicted to die through its use in the 21st century.

Malaria, says Professor Geoffrey Fong, of the University of Waterloo, Canada, may be vicious but “mosquitoes have no lobbyists”. By contrast, he says: “Tobacco is the most effective agent of death ever developed and deployed on a worldwide scale”.

The tobacco industry is arguably winning the battle. Between 1.1 and 1.3 billion people in the world smoke, 82 per cent of whom live in low and middle income countries. Of these, 500 million will die of tobacco-related causes, and by 2025 eight million will die each year. When the cumulative number of tobacco-related deaths is plotted it shows a curve pointing ever upwards, with the figure reaching 520 million by 2050.

Fong asks how we can “flatten the curve”. How can the number of likely deaths from smoking be reduced? How can the health lobby fight back? And how will we know if it succeeds?

National policies are an obvious solution, and 173 nations have become parties to the World Health Organization (WHO) Framework Convention on Tobacco Control. The WHO FCTC is the first international treaty negotiated under the auspices of WHO. Adopted by the World Health Assembly in 2003, it came into force on 27 February 2005, and is one of the most rapidly and widely embraced treaties in the history of the United Nations.

The framework convention was developed in response to the globalization of the tobacco epidemic and has produced a series of evidence-based guidelines on reducing tobacco use. This includes displaying more prominent warning labels on packaging, eliminating “light/mild” brands, banning advertising, creating smoke-free zones, implementing higher taxes and providing more support for cessation programs.

According to Fong, the impact of such policies on the growth curve of tobacco-related deaths will depend on two main factors: when the intervention comes into effect (the earlier the better) and the size of the effect (a larger effect will push down harder on the curve). Late and weak intervention will struggle to flatten the curve very much, whereas early and strong intervention will save many more lives.

In political science the success of treaties is usually measured in terms of whether new policies are implemented at a national level. In the case of the FCTC there is a desire to go deeper than this. Among the questions to consider are: Do smoke free laws work? Why do they work better in some countries than in others? What factors moderate the impact of new polices? Do higher taxes have a stronger effect on youth?

The mission of the International Tobacco Control Policy Evaluation Project, led by Fong, is to evaluate the psycho-social and behavioral effects of tobacco control policies at national level throughout the world. The project follows thousands of adult smokers in 20 countries over five or more years from the survey start date in their respective countries.

The first wave of surveys in each country is administered just before a large FCTC-inspired policy change. The surveys continue over a five year period to monitor the impact of likely FCTC-based policy changes as they are implemented, allowing researchers to perform a series of multiple natural experiments.

In order to explain how policies work, the study traces how the effect of polices on tobacco use behavior is caused by psycho-social factors. It also considers moderating factors – in other words, whether policies work better with, for example, certain socio-demographic groups or with specific personality types.

The study explores different “chains of effect”, depending on the policy. Labels on cigarette packs, for example, may increase the intention to quit by virtue of eliciting negative emotion and changing the perceive risk from smoking. An advertising ban, meanwhile, may encourage attempts to quit by reducing the positive associations of smoking.

The ITC project measures the same variables across different countries and retains participants from year-to-year to monitor change in overall attitudes, knowledge, or behavior. It started in Australia, Canada, the UK and the US, where a seventh wave of data is being collected. Other ITC countries joined the project subsequently and are therefore in different waves of data collection.

Most of the ITC countries use telephone interviews, although some countries, such as Malaysia and China, use a mixture of telephone and face-to-face interviews. The 20 countries involved contain over 50 per cent of the world’s population, 60 per cent of its smokers and 70 per cent of tobacco users, which includes chewing tobacco.

Evidence so far shows a high global demand for cessation, yet low rates of professional health advice to quit smoking in many countries. The study also reveals that large pictorial warnings are more effective than text-only warnings, supporting the case for strong implementation of the FCTC Article 11 Guidelines, which recommend pictorial warnings on at least 50 per cent of the pack.

The study is arguably a model for the evaluation of policies. Whether it will reveal a flatter curve in terms of fewer tobacco-related deaths than predicted remains to be seen, but the fight back has begun, and it is being watched closely.

Reference
Fong, G. T. (2011) The International Tobacco Control Policy Evaluation Project (the ITC Project): Evaluating the Impact of the WHO Framework Convention on Tobacco Control. Plenary Paper at the 19th Annual Meeting of the Society for Prevention Research, Washington DC, 1st June 2011.