MPOWER Brochure

Monitor tobacco use and prevention policies

The WHO Framework Convention on Tobacco Control states:

Article 20The Parties shall establish … surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke.

… Parties should integrate tobacco surveillance programmes into national, regional and global health surveillance programmes so that data are comparable and can be analysed at regional and international levels …

Population-based national and international monitoring data are necessary to effectively plan and implement the WHO Framework Convention on Tobacco Control (WHO FCTC).

Only through accurate measurement can problems caused by tobacco be understood and interventions be effectively managed and improved.

Monitoring can provide policy-makers and public health authorities with essential information on:

● The extent of the tobacco epidemic in a country

● Subgroups in need of tailored policies and programmes

● Public awareness of the epidemic and attitudes towards tobacco control

● Changes in tobacco use following implementation of policies and programmes

● Government enforcement and societal compliance with tobacco control policies, including tax collection and tax evasion, smoke-free places, and advertising and marketing bans

● Tobacco industry practices that may increase tobacco use or hinder implementation of tobacco control policies and programmes

Monitoring is also essential to evaluate the effectiveness of MPOWER implementation. Currently, monitoring systems are weak in many low- and middle-income countries, where tobacco use is rising fastest.

Many countries do not have monitoring dataAll countries need effective tobacco surveillance systems. However, many countries lack national smoking prevalence data for adults and youth, or have older data or data that are not representative.

Data on other aspects of the epidemic – such as tobacco-related disease and death, the economic costs of tobacco use, public attitudes towards tobacco control and the extent of tobacco marketing – are also inadequate.

Assessment of tobacco use and its impact must be strengthened, as monitoring at both global and country-by-country levels is critical to understanding and contributing to the information base necessary to reverse the tobacco epidemic.

Monitoring must be scientifically validAny monitoring system must use standardized and scientifically valid data collection and analysis practices.

Surveys that use a random population-based sample of sufficiently large size can provide accurate estimates of tobacco use at the national level within an acceptable margin of error. Moreover, surveying a sufficiently large sample enables accurate estimates of smoking prevalence among major subpopulations – classified by age, gender, income, region and other sociodemographic characteristics.

Surveys should be implemented at regular intervals to ensure that changes in the epidemic are measured.

Monitor Monitor tobacco use and prevention policies

Protect Protect people from tobacco smoke

Offer Offer help to quit tobacco use

Warn Warn about the dangers of tobacco

Enforce Enforce bans on tobacco advertising, promotion and sponsorship

Raise Raise taxes on tobacco

The WHO Framework Convention on Tobacco Control (WHO

FCTC) is the pre-eminent global tobacco control instrument,

which contains legally binding obligations for its Parties

and provides a comprehensive direction for tobacco control

policy at all levels. WHO introduced the MPOWER package

of measures to assist in the country-level implementation

of effective measures to reduce the demand for tobacco,

contained in the WHO FCTC.Additional resources on this topic are available at www.who.int/tobacco/mpower/publications

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PERcEntagE OF gLOBaL POPULatIOn cOVERED BY , 2008

Monitoring is a critical tobacco control activity

technical input and assistance in publication was provided by the International Union against tuberculosis and Lung Disease (the Union) with funding from Bloomberg Philanthropies and support from World Lung Foundation. Data from 2008. Source: WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva, World Health Organization, 2009.

Monitor tobacco use and prevention policies

Conducting effective surveysSurveys can be conducted on tobacco use alone, or can be combined with surveys on other health issues of interest to a country’s government.

Standardized questions about tobacco use prevalence and implementation of MPOWER measures to reduce tobacco use can be embedded in existing population-based surveys or censuses.

Surveys should be repeated at regular intervals, using the same survey questions and sampling and data analysis techniques. This enables data from different surveys to be comparable, allowing accurate evaluation of the impact of interventions over time.

Partners can assist with surveysStatistically valid surveys can be expensive to conduct. Costs rise further if large populations are surveyed on a number of different measures.

Survey partners with sufficient technical capacity – such as national statistics offices, universities and private research firms – can be enlisted. These partners can support monitoring activities, including survey administration and data collection, management and analysis.

Consistent data collectionStandardized questions and surveillance measures are vital. It is important to coordinate with tobacco control partners to ensure the development of consistent surveys.

Key indicators are included in the Global Adult Tobacco Survey (GATS), a nationally representative household survey, which feeds into the Global Tobacco Surveillance System.

The Global Youth Tobacco Survey (GYTS) is a school-based survey of students aged 13–15 years that also informs the Global Tobacco Surveillance System.

There are two key questions when surveying prevalence of tobacco use:

● What types of tobacco are used?

● How many people use tobacco?

Key indicators for monitoring the baseline and impact of tobacco control policies include:

● Exposure to second-hand smoke in public places, at work and at home

● Price paid for tobacco and purchase location

● Exposure to tobacco advertising

● Exposure to tobacco pack warning labels and anti-tobacco counter advertising

● Beliefs about the health harms of tobacco

● Physician advice to quit and cessation attempts

The proportion of former smokers (people who have ever smoked regularly and have quit) is a useful indicator of progress in tobacco control.

Studies for effective tobacco controlFor the effective development and implementation of tobacco control policies and to increase stakeholder support, a range of localized studies may also prove useful. These could include:

● Assessments of government enforcement of tobacco control policies, and tobacco industry and societal compliance with them

● Polls to measure public acceptance of tobacco control initiatives and perceived levels of compliance with policies

● Epidemiologic studies to determine the burden of tobacco-related illness and death and the impact of tobacco control interventions on health

Economic research can provide important information on both tobacco use and the impact of tobacco control policy. Examples include:

● Studies to determine the economic impact of particular tobacco control policies, including gains associated with reductions in tobacco-related death and ill-health

● Estimates of per capita consumption of tobacco, based on sales, tax, manufacturing, import and export data

● Studies to determine the economic costs of smoking and second-hand smoke, from direct medical expenses as well as productivity losses

● Calculation of revenues generated by tobacco excise taxes and disbursements for tobacco control programs

Monitoring the tobacco industry is important for effective adaptation of tobacco control policy. Key issues include:

● The extent and type of tobacco advertising, marketing and promotional activities – including tobacco industry sponsorship of public and private events

● Tobacco industry interference with the development and implementation of effective tobacco control measures

National and global collaboration is neededTo maintain an effective monitoring system, collaboration is needed – within countries and internationally – among health practitioners, economists, epidemiologists, data managers, government officials and many others.

GATS can guide efforts to collect internationally comparable data.GATS surveys use common sampling procedures, core questionnaires and data management across countries.

Publicize findingsData that highlight the burden of tobacco use, as well as the status and effectiveness of tobacco control policy implementation, should be emphasized.

Data from monitoring can become critical evidence to promote stronger policies.

Findings should be disseminated through government policy papers, academic publications and mass media (news reports, as well as paid media).

Broad dissemination of survey findings allows governments, country leadership and civil society to use them to develop tobacco control policies. This also helps build capacity for effective policy development, implementation and enforcement.

Pretesting the gatS questionnaire in Indore, Madhya Pradesh, India.

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collecting global adult tobacco Survey data from a fisherman in south-western Bangladesh. ©

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conducting the gatS in Wuhan, Hubei Province, china. ©

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analysing gYtS data in Brazzaville, congo.

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Protect people from tobacco smoke


Article 8

… scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability.

Each party shall adopt and implement … measures, providing for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.

Second-hand smoke exposure is deadlyThere is no safe level of exposure to tobacco smoke. Exposure to tobacco smoke is proven to cause heart disease, cancer and many other diseases.

Just 30 minutes of exposure to tobacco smoke changes the way in which blood flows and clots, increasing the risk of heart attack and stroke. Second-hand smoke kills more than 600,000 people each year. In many countries, it causes more than 10% of all tobacco-related deaths.

Only 100% smoke-free environments protect healthAll people have a fundamental right to breathe clean air. Completely smoke-free indoor environments – with no exceptions – are the only proven way to protect people.

100% smoke-free environments require the elimination of all smoking and tobacco smoke indoors. Ventilation cannot protect against the health risks of tobacco smoke.

Do not allow exemptionsProtection from tobacco smoke should be universal: all people deserve health protection, all the time.

Exceptions to 100% smoke-free indoor environments – such as permitting smoking in designated areas or installing ventilation systems – do not protect health.

The tobacco industry has acknowledged the effectiveness of smoke-free environments. Their data show that exceptions to 100% smoke-free environments undermine the impact of such regulations.

Smoke-free laws are popularExperience consistently shows that smoke-free laws are practical, popular – even among smokers – and successful, despite industry claims to the contrary.















In 2008, 114 cOUntRIES LackED OR HaD MInIMaL SMOkE-FREE LEgISLatIVE PROtEctIOn

Smoke-free laws do not hurt businessA review of the economic effects of smoke-free environments around the world concludes that they do not have a negative economic impact on businesses. In many cases, smoke-free laws have even had a slight positive economic impact.

Economic impact studies of smoke-free laws have shown no adverse effect on bar and restaurant businesses or tourism. Evidence of this type can be used to counter false tobacco industry claims.

Smoke-free laws protect worker healthThe primary purpose of establishing smoke-free workplaces is to protect workers’ health.

Framing the debate about smoke-free workplaces as a worker safety issue can help build support.

The International Covenant on Economic, Social and Cultural Rights recognizes the right of all people to safe and healthy working conditions. Workers have the right to earn a living without endangering their health by breathing second-hand smoke.

Clean air – a basic human right

Not categorized

Up to two categories of public place (health-care, educational and government facilities, universities, indoor offices, restaurants, pubs, bars and public transport) completely smoke-free

Three to five categories of public place completely smoke-free

Six to seven categories of public place completely smoke-free

All public places completely smoke-free (or at least 90% of the population covered by complete subnational smoke-free legislation)

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Proportion of countries (Number of countries inside bars)

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technical input and assistance in publication was provided by the International Union against tuberculosis and Lung Disease (the Union) with funding from Bloomberg Philanthropies and support from World Lung Foundation.

Data from 2008. Source: WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva, World Health Organization, 2009.

Protect people from tobacco smoke

Smoke-free laws help smokers quitSmoke-free environments help smokers who want to quit.

Cigarette consumption in the United States is between 5% and 20% lower per capita in states with comprehensive smoke-free laws.

In a review of smoke-free workplaces, the average consumption of cigarettes fell by 3.1 cigarettes per day per smoker compared to workplaces that were not smoke-free.

Protect children, the sick and all workersSmoke-free regulations can be easily enacted in facilities under direct government control or regulation.

It is relatively easy to gain support for protecting children and the sick through smoke-free schools and health-care facilities.However, the vast majority of people in most countries are employed by the private sector. It is therefore important to make all indoor workplaces smoke-free to protect the largest number of people.

Make restaurants and bars smoke-freeRestaurants, bars and other hospitality venues are also workplaces and should be covered by smoke-free workplace policies.

It is important to counter the perception that smoking is integral to restaurants, bars and other hospitality venues.

Public opinion polls showing strong support for making restaurants and bars 100% smoke-free are important in securing support for legislation among businesses and policy makers.

Smoke-free laws lead to smoke-free homesFor children and adults who do not work elsewhere, most exposure to second-hand smoke takes place at home.

Establishing smoke-free public places encourages families to make their homes smoke-free. This protects children and other family members from the dangers of second-hand smoke.

Teenagers who live in homes where smoking is allowed are nearly twice as likely to start smoking than those in homes where smoking is prohibited.

Smoke-free laws change social normsSmoke-free environments contribute to changing the social norm to make smoking less acceptable. This helps to further reduce both smoking and exposure to tobacco smoke.

Counter tobacco industry myths The tobacco industry and its allies have tried to stop, delay and weaken 100% smoke-free policies by interfering and misinforming at different stages of smoke-free development and implementation.

Myths, such as the threat of economic loss, continue to be spread by the tobacco industry. These myths and opposition can be anticipated and countered.

Any country can implement smoke-free laws

Experience in a growing number of countries and sub-national areas shows it is possible to enact and enforce effective smoking bans, and that doing so:

● is popular with the public

● improves health

● does not harm businesses

Too often, smoke-free laws cover only some indoor spaces, are weakly written or are poorly enforced.

Gain support for smoke-free lawsPublic support is critical to the success of smoke-free laws. Support can be gained through effective education about the harms of second-hand smoke exposure and a clear explanation of the purpose of the law.

Health-care professionals and non-governmental organizations involved with health, education, child protection, women’s issues and human rights are important allies in gaining support from both the public and political leaders. Support of trade unions and other worker groups is critical to implementing workplace smoking bans.

Effective smoke-free legislationSmoke-free legislation should be clearly written and comprehensive. There should be no exemptions and there should be clear responsibility for enforcement.

The law should clearly define the act of smoking, specify all indoor areas covered, and mandate posting of clear and conspicuous signage.

The government agency responsible for enforcement should be clearly defined, as should penalties for violations.

Enforcement is necessaryOnce enacted, laws establishing smoke-free places must be well enforced.

Administrators, managers or proprietors, rather than individual smokers, should bear primary responsibility for ensuring enforcement.Although maintenance of smoke-free places is largely self-enforced in the long-term, it may be necessary to increase the level of enforcement immediately after smoke-free laws are enacted.

Once there is a high level of compliance, it is usually possible to reduce enforcement measures, with regular monitoring.

a road sign welcome visitors to chandigarh, India, a smoke-free city.

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a no-smoking sign erected under city-wide smoke-free laws in Mexico city. ©

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Signage from smoke-free chao-Yang Hospital, Beijing, china.

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campaigning for smoke-free public transport in Bangladesh.

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Any country, regardless of income level, can develop and introduce smoke-free laws effectively by following the Article 8 Guidelines for implementation of the WHO FCTC.

Offer help to quit tobacco use


Article 14

Each Party ... shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

Each Party shall endeavour to design and implement effective programmes aimed at promoting the cessation of tobacco use [and to] include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies ...

More than one billion smokers worldwide – a quarter of all adults – are victims of the tobacco epidemic. Like people dependent on any addictive drug, it is difficult for tobacco users to quit. However, most people want to quit when informed of the health risks.

Tobacco control policies create the environment in which users can successfully stop. Cessation support and medication can increase the likelihood that a smoker will quit successfully. However, few smokers currently receive the help and support they need to overcome their dependence.

Health-care systems are responsible for treatmentTobacco dependence treatment is primarily the responsibility of each country’s health-care system.

Countries should establish programmes that provide low-cost, effective interventions for tobacco users to stop.

Cost analyses have shown the benefits from tobacco cessation programmes to be either cost-saving or cost-neutral.

Yet, few smokers currently receive the help and support they need to overcome their dependence.

Three primary forms of treatmentTreatment includes various methods, but programmes should include:

● Tobacco cessation advice incorporated into primary and routine health-care services

● Easily accessible and free telephone help lines (known as quit lines)

● Access to free or low-cost cessation medicines

These methods work best when adapted to local conditions and cultures, and tailored to individual preferences and needs.

Quit advice from all health professionals is effectiveClear, strong, personalized advice from all health professionals about the risks of tobacco use and the importance of quitting is usually well-received and increases quit rates.

Brief advice (1-3 minutes) is inexpensive when integrated into existing health-care services.

Health-care systems should encourage all health professionals to routinely ask all patients about their tobacco use and provide advice to stop.

All health-care workers must be motivated to provide advice.















Few smokers get the help they need

Cessation services and cessation supportAll health professionals should offer cessation support to smokers, or refer smokers to a cessation service where possible.

Cessation support includes:

● Promoting the benefits of cessation

● Assessing the degree of nicotine dependence

● Assisting smokers in setting a quit date

● Advising that complete abstinence from smoking is best

● Arranging effective medication, if available

● Arranging follow-up

All health-care workers should be trained in giving brief advice to quit and offering cessation support to tobacco users. technical input and assistance in publication was provided

by the International Union against tuberculosis and Lung Disease (the Union) with funding from Bloomberg Philanthropies and support from World Lung Foundation.

In 2008, SMOkERS In 98 cOUntRIES HaD tO PaY FOR anY tOBaccO DEPEnDEncE tREatMEnt. In 23 cOUntRIES nO tREatMEnt WaS aVaILaBLE

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National quit line, and some cessation services and nicotine replacement therapy (NRT) cost covered.

Some cessation services and/or NRT, at least one of which is cost-covered.

Some cessation services and/or NRT, neither cost covered.

None

Data not reported

Data from 2008. Source: WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva, World Health Organization, 2009.

Offer help to quit tobacco use

Health professionals should not smokeDoctors and other health-care workers are most effective in assisting patients to quit when they serve as role models by not smoking themselves. Their effectiveness increases further if they are visibly involved in local and national tobacco control activities.

In some countries, a high proportion of physicians smoke – particularly male physicians. In addition to setting a deadly example for their patients, doctors who smoke undermine tobacco control messages and policies.

Quit lines are effectiveAdvice and counselling can also be provided in the form of telephone quit lines. These should:

● Be free of charge

● Provide information similar to that available from in-person counselling

● Be staffed by live operators, rather than use pre-recorded messages

● Be accessible to the public at convenient times

Where feasible, additional cessation materials and links to more intensive counselling should be provided.

Quit lines are most useful in countries where telephone service is universal and the public is accustomed to making phone calls for services.

Quit lines require financing and training of staff to answer incoming calls and provide appropriate counselling or referral for services.

Quit line follow-up is importantQuit lines are most effective when staff take proactive measures to make follow-up phone calls to check on progress and provide encouragement to:

● Quit

● Maintain abstinence

● Make another quit attempt in case of relapse

Multiple follow-up calls at regular intervals have the greatest likelihood of keeping people committed to long-term cessation.

Emerging communications technologies such as text messaging and social networking web sites can also be effective.

Cessation medications are effectiveCessation medications can double or triple the likelihood of successfully quitting.

The highest quit rates are achieved when cessation support is combined with medication. Medication is also effective when provided separately.

Prescription medications should be provided through the health-care system. At least some form of nicotine replacement therapy (NRT) should be available over-the-counter without prescription at retail pharmacies.

There are two main types of cessation medication available:

● NRT (patches, lozenges, gum, oral inhalers and nasal spray).

● Prescription-only medicines such as bupropion and varenicline. These are intended for short-term therapy.

Two forms of NRT are included on the WHO Model List of Essential Medicines.

Cessation programmes are politically feasibleCessation programmes generally encounter few political obstacles. They help foster support for policies to reduce tobacco use, an important step in creating a tobacco-free society.

Cessation programmes enable governments to help those most directly affected by the epidemic at the same time as they enact new restrictions on tobacco.

Most countries can use lower-cost counselling options effectively, even if funds for medications are limited.

This may also reduce opposition to other tobacco control policies.

Governments can use tobacco tax revenues – ultimately collected from smokers themselves – to subsidize cessation services.

Cessation services are cost-effectiveClinical cessation services are much more cost-effective than most other health-care system activities. They are most effective when combined with other MPOWER measures.

While cessation services have a smaller population impact than other MPOWER interventions (such as tax increases, bans on advertising, promotion and sponsorship, anti-tobacco advertising and establishment of smoke-free places), they have a great impact on individual health.

The risks of developing a tobacco-related illness are significantly reduced within a few years among those who quit smoking before they develop such an illness, regardless of their age.

Quit line details on a cigarette packet, australia.

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Measuring lung function on World no tobacco Day in Mexico city to encourage cessation. ©

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nicotine gum.

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cessation advice area at a hospital in Beijing, china.

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Warn about the dangers of tobacco


Article 11

Each Party shall … ensure that tobacco product packaging and labelling do not promote a tobacco product by any means that are false, misleading [or] deceptive …

Each Party shall … ensure that… tobacco products … carry health warnings describing the harmful effects of tobacco use …

Article 12

Each Party shall promote and strengthen public awareness of tobacco control issues, using all available communication tools …

Despite conclusive evidence on the dangers of tobacco, few tobacco users worldwide understand the full extent of the health risks.

Many smokers believe that they can reduce or stop tobacco use before health problems occur.

Both smokers and non-smokers underestimate the addictiveness of tobacco and the risk it poses to health. Both smokers and non-smokers also underestimate the danger of exposure to second-hand tobacco smoke. These threats have not been adequately explained to the public.

The need for public education is even more pronounced in low- and middle-income countries, where tobacco use is on the rise and tobacco control is generally in its early stages.

Effective warning labels, anti-tobacco advertising and the proactive use of media to influence the public and policy-makers are three key ways to communicate the health risks of tobacco .

Warning labels increase awareness of health risksProminent warning labels on tobacco packs are the most direct way of communicating health risks to tobacco users.

Effective health warnings on cigarette packs encourage smokers to quit and discourage non-smokers from starting.

Best practice warning labels, that comply with the Guidelines for implementing Article 11 of the WHO Framework Convention on Tobacco Control (WHO FCTC), reach all tobacco users, increase their awareness of health risks, are well-accepted by the public and cost governments virtually nothing.

Warnings change the image of tobaccoComprehensive warnings about the dangers of tobacco are critical to changing its image, especially among adolescents and young adults.

People need to associate tobacco use with its actual human impact, extreme addictiveness and dangerous health consequences, and to see it as socially undesirable and negative.

Health warnings and anti-tobacco advertising encourage tobacco users to quit and help keep young people from starting.

Warnings and anti-tobacco advertising also help gain public acceptance of other tobacco control measures such as establishing smoke-free environments.















56% changed their opinion about health consequences

of smoking

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Source: Datafolha Instituto de Pesquisas. Opinião pública, 2002.

Impact of pictorial warnings on Brazilian smokersSMOkERS APPROvE OF PICTORIAL WARNINGS

76% approve of health warnings

73%

Few smokers and non-smokers fully understand the health risks of tobaccoWarning labels on tobacco packaging and hard-hitting mass media campaigns provide crucial information about the dangers of tobacco use.


Warn about the dangers of tobacco

Characteristics of effective warning labelsBest practice health warning labels should:

● Describe the harmful effect of tobacco use

● Be large, clear, visible, and legible, covering 50% or more of principal pack display areas (both front and back) and in no case less than 30%

● Rotate periodically so that they continue to attract the attention of the public

● Appear in the country’s principal language(s)

● Include graphic pictures

● Be approved by the competent national authority

Misleading descriptorsStudies show that more than half of smokers incorrectly believe that the terms “light” and “ultra-light” refer to cigarettes that are less harmful to their health. Misleading descriptors – such as ‘low tar’, ‘light’, and ‘mild’ – and any packaging that creates a false impression of the product being less harmful should be banned.

Tobacco packaging that creates a false impression of the product being less harmful than other forms of tobacco should be banned.Tobacco packaging should contain information on relevant constituents and emissions of tobacco products. However, statements about tobacco constituents and emissions must not imply that a product is less harmful than other tobacco products.

Maximizing the impact of warning labelsThere are several ways to maximize the effectiveness of warning labels:

● Use pictures with graphic, culturally appropriate depictions of disease and other negative images in full color. Pictures have more impact on most smokers than words alone. They are also critical in reaching the large number of people worldwide who cannot read.

● Elicit unfavorable emotional associations with tobacco use by addressing harmful health effects, addiction potential and adverse social and economic consequences.

● Use strong and clear language that describes specific diseases caused by tobacco use and exposure to second-hand smoke.

● Other required packaging, labelling or markings should not obstruct warning labels.

● Measures mandating plain and generic packaging that prohibits the use of logos, brand images, or promotional information should be considered.

In Singapore, where highly graphic warnings are used, 71% of smokers said they knew more about the health effects of smoking because of warning labels.

Anti-tobacco advertising increases awareness of health risksAnti-tobacco advertising in all forms of media can help publicize the full extent of tobacco’s dangers.

When exposed to graphic anti-tobacco messages on television, smokers are more likely to quit.

Campaigns using graphic images that demonstrate the physical harm caused by tobacco use are especially effective in convincing users to quit.

High-quality advertising is feasibleSustained, highly visible and effective counter-advertising campaigns can be expensive. However, advertising can be easily and inexpensively adapted from content that has been used successfully in other countries.

Obtaining free or low-cost television and radio time can also reduce costs. In Turkey, all television and radio channels are required to devote 90 minutes of free airtime each month to tobacco control and addiction, including 30 minutes of prime time. Remaining costs can be covered through tobacco tax or other government revenues.

Professional companies, including advertising agencies, should be used to develop creative materials, especially for television. Anti-tobacco advertising should have the same production quality and persuasive power as tobacco industry propaganda.

Advertising should be systematically tested with focus groups before being run to ensure that anti-tobacco messaging has the intended effect.

“Earned media” is effective and inexpensivePublic relations activities can further educate people about the harms of tobacco and counter tobacco industry misinformation. As such, anti-tobacco educational campaigns should include efforts to obtain news coverage by working with journalists to develop stories or writing letters to the editor.

This is sometimes referred to as “earned media” because, unlike advertising, no space or air time is purchased, so costs are relatively low.

Public relations efforts should be proactive and engage the media whenever there are developments in tobacco control.

The media will usually cover the following events as news:

● Introduction or passage of new laws in agreement with the WHO FCTC

● Implementation of MPOWER measures such as smoke-free places, anti-tobacco advertising and pack warnings

● Launch of an anti-tobacco advertising campaign

● Release of new research findings

Advocates need to make sure factual tobacco control messages are included in any related press.

The media can also be encouraged, to reveal industry marketing and lobbying tactics, cover the health and economic harms of tobacco, highlight the progress of tobacco control in local communities or feature anti-tobacco outreach activities conducted by youths.

Local stories with strong human interest angles and backed with facts are likely to gain the greatest attention from media and their audiences.

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One of ten graphic pack warnings required in Brazil.

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‘cigarettes cause lung cancer’: one of nine pack warnings, thailand.

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anti-tobacco advertising about the health harms of secondhand smoke, Sao Paulo, Brazil. ©

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Enforce bans on tobacco advertising, promotion and sponsorship


Article 13

… a comprehensive ban on advertising, promotion and sponsorship would reduce the consumption of tobacco products.

Each Party shall … undertake a comprehensive ban of all tobacco advertising, promotion and sponsorship.

The tobacco industry spends tens of billions of US dollars worldwide each year on marketing through advertising, promotion and sponsorship.

Advertising, promotion and sponsorship normalize tobacco, making it seem like any other consumer product. This increases its social acceptability and hampers efforts to educate people about the hazards of tobacco use.

Marketing falsely associates tobacco with desirable qualities such as energy, glamour and sex appeal. It also strengthens the tobacco industry’s influence over media, sporting and entertainment businesses.

In countries where partial bans prohibit direct advertising and promotion of tobacco products in traditional media, tobacco companies frequently employ indirect marketing tactics to circumvent the restrictions. Tactics include:

● sport and music event sponsorship

● pack designs and displays

● branded merchandise

● product placement

● alleged corporate-social responsibility activities

● new media technology campaigns

Advertising, promotion and sponsorship bans workComprehensive bans on direct and indirect advertising, promotion and sponsorship protect people – particularly youth – from industry marketing tactics and can substantially reduce tobacco consumption.

Comprehensive bans significantly reduce the industry’s ability to market to young people who have not started using tobacco and to adult tobacco users who want to quit.

Comprehensive bans can be achieved by following the international best practice standards outlined in the Guidelines for implementation of Article 13 of the WHO Framework Convention on Tobacco Control (WHO FCTC).A comprehensive ban on all advertising and promotion reduces tobacco consumption by about 7%, independent of other interventions. Some countries have seen consumption drop by as much as 16%.

Bans must be comprehensiveTo be effective, bans must be comprehensive and apply to all types of advertising, promotion and sponsorship – both direct and indirect.Bans on direct advertising should cover all types of media – including print, broadcast, billboards and other outdoor advertising (such as on transit vehicles and stations), and the internet.

Legislation should include bans on in-coming and out-going cross-border advertising, such as tobacco advertising on international television and Internet sites, and sponsorship of international sporting and cultural events.

Bans should also cover promotional strategies such as price discounts and free product giveaways.

Ban point of sale advertising and promotionPoint of sale promotion – including price discounts and product giveaways – can account for more than 75% of tobacco company marketing expenditure.

Point of sale advertising and in-store displays of tobacco products should be banned. Bans on product display lead to reductions in youth smoking and also reduce impulse purchases among adults wanting to quit.

Keeping tobacco behind the counter and out of public view can be effective. Even the extra effort required to ask a retailer for tobacco products is often enough to deter purchasers.

Certain countries are beginning to require generic packaging of tobacco products. Requiring plain or generic packaging – without colour, pictures or distinctive typefaces, other than health warnings – can neutralize the value of individual brands.















Data Source: World Health OrganizationMap Production: Public Health Informationand Geographic Information Systems (GIS)World Health Organization

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoeveron the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2009. All rights reserved

Best practice countries

Enforce bans on tobacco advertising, promotion and sponsorship - best practice countries, 2008

EnFORcE BANS ON TOBACCO ADvERTISING, PROMOTION AND SPONSORSHIP – HIGHEST ACHIEvING COuNTRIES, 2008

The tobacco industry spends billions to market its deadly products

technical input and assistance in publication was provided by the International Union against tuberculosis and Lung Disease (the Union) with funding from Bloomberg Philanthropies and support from World Lung Foundation. Source: WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva, World Health Organization, 2009.

Enforce bans on tobacco advertising, promotion and sponsorship

Ban all forms of indirect advertising and promotionAll forms of indirect tobacco advertising promotion and sponsorship should be banned, including:

● Sponsorship of music, cultural and sporting events

● Use of non-tobacco products to promote tobacco brands or companies

● Endorsement by celebrities

Measures should also be put in place to severely restrict tobacco imagery in entertainment media such as films and television.

Tobacco companies invest in sophisticated branding to promote their products. In many low- and middle-income countries, more than a third of young people own an object with a cigarette brand logo. Prohibiting the use of tobacco branding on clothing and other items can counter this powerful technique.

It is also important to prohibit free giveaways of tobacco and related products.

Tobacco companies frequently engage in activities that they categorize as ‘corporate social responsibility’ (CSR), including sponsorship of research, charities and community projects. CSR is intended to improve the image of tobacco companies as socially acceptable economic contributors and persuade governments not to implement policies that may reduce tobacco sales. Bans on this form of promotional activity are another important part of comprehensive tobacco control.

Partial bans do not workPartial bans have little or no effect because the industry simply diverts resources to other types of advertising, promotion and sponsorship.For example, if only broadcast advertising is banned, other types of marketing (such as newspaper and magazine, billboard, point of sale and Internet) will proliferate.

If direct advertising is banned, sponsorship of events popular among young people – such as racing, sports and music festivals – may expand. Often, partial bans fail to include all indirect or alternative forms of promotion.

Implementing effective bansPolicy-makers should announce bans on advertising, promotion and sponsorship well in advance of implementation. This provides sufficient time for media and other businesses to find new advertisers and sponsors.

Comprehensive bans on advertising, promotion and sponsorship must be periodically updated to take account of innovations in industry tactics and media technology.

Legislation should not include exhaustive lists of prohibited activities, so as to cover future developments in marketing technology and tactics. Examples of prohibited advertising, promotion and sponsorship are useful in legislation, provided that it is clear that they are examples only.

Monitoring and enforcement are keyTobacco industry advertising, promotion and sponsorship activities should be monitored to ensure compliance with bans.

Monitoring should cover traditional media and marketing channels, as well as novel and emerging marketing strategies.

It is also important to include new technologies and social trends, such as text messaging, chat groups and underground nightclubs advertised through word-of-mouth, in monitoring and enforcement programmes.

Strong legislation is requiredThe industry often argues that outright bans on advertising, promotion and sponsorship are not necessary and that voluntary codes and self-regulation are sufficient. However, voluntary agreements or codes do not work because they are unenforceable. In addition, voluntary codes do not cover tobacco retailers and consequently fail to prevent point of sale advertising or displays, some of the most common and insidious forms of marketing.

Governments should act to ban tobacco advertising, promotion and sponsorship through well-drafted and well-enforced laws. The industry is increasingly aggressive at circumventing prohibitions on marketing activities that are designed to reduce tobacco use.

Financial penalties should be substantial. The tobacco industry is often willing to pay fines that are small in comparison to the additional business gained by marketing.

Countering industry oppositionThe tobacco industry strongly opposes bans on advertising, promotion and sponsorship because they are highly effective in reducing tobacco use.

The industry also claims that bans restrict its right to free speech, including the right to promote a legal product.

These claims can be countered:

● Assert the right and duties of governments to protect the health and rights of citizens.

● Highlight the fact that many governments ban or restrict advertising of other legal products, such as firearms and medications, as part of consumer protection laws.

● Emphasize the health and economic damage caused by tobacco.

● Call attention to the evidence that links tobacco advertising, promotion and sponsorship to increased overall consumption and uptake among youth.

People’s right to live free from harm and addiction overrides the financial interests of the tobacco industry.

tobacco advertising in Malaysia.

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Dance party sponsored by Surya cigarettes, nepal.

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Raise taxes on tobacco


Article 6

Price and tax measures are an effective and important means of reducing tobacco consumption … Each Party should … adopt … tax policies and … price policies on tobacco products, so as to contribute to the health objectives aimed at reducing tobacco consumption.

Article 15

Elimination of all forms of illicit trade in tobacco products, including smuggling, illicit manufacturing and counterfeiting … are essential components of tobacco control.

Increasing the retail price of tobacco products through higher taxes is the single most effective way to decrease consumption and encourage tobacco users to quit.

When tobacco prices increase:

● Fewer people use tobacco

● People who continue to use tobacco, consume less

● People who have quit are less likely to start again

● The young are less likely to start using tobacco

Tobacco taxes are generally well accepted – and even supported by many tobacco users – because most people understand that tobacco is harmful.

In high-income countries, a 10% increase in tobacco prices will reduce consumption by about 4%. The effect of higher prices on reducing consumption is likely to be greater in low- and middle-income countries.

Tobacco taxes protect the poor and the youngTobacco taxes are particularly effective in preventing or reducing tobacco use among the young and the poor. People in these groups are more affected by price increases.

Tax increases help the poor to stop using tobacco. This allows tobacco users who quit to reallocate their money to essential goods, including food, shelter, education and health-care.

Higher taxes also help poor families improve productivity and wage-earning capacity by decreasing tobacco-related illness and death.

Have a simple and effective tax structureThere are two main types of tobacco excise taxes:

● Specific taxes – levied on a given quantity of tobacco, such as a tax paid per pack or carton of cigarettes

● Ad valorem taxes – based on a percentage of the wholesale or retail price

In some countries, a combination of excise taxes is used.

● Specific taxes provide more predictable revenue and make it harder for the tobacco industry to influence retail prices.

● Ad valorem taxes help tobacco prices maintain pace with inflation.

The overall tax structure should be simple and easy for countries to implement.

Excise taxes should be levied at the manufacturer level, rather than at the distributor or retail level. This helps increase effectiveness by centralizing revenue collections and minimizing recordkeeping burdens on small businesses.







The WHO Framework Convention on Tobacco Control

(WHO FCTC) is the pre-eminent global tobacco control

instrument, which contains legally binding obligations

for its Parties and provides a comprehensive direction for

tobacco control policy at all levels. WHO introduced the

MPOWER package of measures to assist in the country-level

implementation of effective measures to reduce the demand

for tobacco, contained in the WHO FCTC.Additional resources on this topic are available at www.who.int/tobacco/mpower/publications

When South Africa increased its taxes, smoking rates among the poor and the young plummeted. Yet tax revenues increased.

When tobacco prices go up, consumption goes down

tOBaccO TAxES REDuCE CONSuMPTION

Relationship between cigarette consumption and excise tax rate in South Africa

Source: WHO Report on the Global Tobacco Epidemic, 2008. The MPOWER package. Geneva, World Health Organization, 2008.

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Consumption (left scale)

Excise tax rate (right scale)


Increase taxes regularlyThe goal of tobacco taxation is to reduce consumption by making tobacco products progressively less affordable.

Governments should raise taxes periodically so that real prices increase faster than the combined effects of inflation and increased consumer purchasing power.This is best accomplished by automatically linking tax increases to economic indices. Otherwise tobacco becomes relatively more affordable over time.

Seek expert adviceDifferent tobacco taxation schedules may raise the same amount of revenue, but may either greatly reduce or have little impact on consumption rates.

Expert consultation is important when establishing a taxation system that has health goals – such as reducing smoking – in addition to economic goals of raising revenue.

Economic experts can also provide evidence demonstrating that higher taxes reduce tobacco consumption, increase government ability to fund programmes and do not hurt the poor.

Avoid product substitutionIf taxes increase the prices of more expensive products without significantly increasing prices of cheaper ones, many tobacco users will shift to less expensive brands rather than reduce consumption.

Taxes should be increased on the most commonly smoked and lowest-cost products to prevent product substitution with less expensive products.

Higher taxes do not mean more smugglingContrary to tobacco industry claims, increased smuggling does not automatically follow tax increases.

Tax evasion correlates more closely with poor governance than it does with high levels of taxation.

A streamlined system under a single taxation authority that focuses on manufacturers, with strong tax administration and customs enforcement, facilitates compliance.

Stringent law enforcement costs only a small fraction of the additional revenue earned from higher tobacco taxes.

Large financial penalties should be imposed for large-scale tax evasion and smuggling operations.

Implement measures to combat tax evasion and smugglingTax evasion and smuggling can be reduced through:

● Effective government record keeping

● Improved border security and inspection procedures

● Banking controls to reduce money laundering

● Better communication among finance, customs and other agencies involved in tax collection and enforcement

Affixing tax stamps to every package intended for retail sale and mandating pack warnings in local languages further reduce incentives for illicit trade.Taxes can be levied on tobacco imports at the port of entry as with any other customs duty. The same taxes should be levied on imported cigarettes as on domestically manufactured cigarettes. Duty-free sales of tobacco products should be banned.

Use tobacco taxes to pay for better healthA tax increase directly benefits governments through increased revenues, at least in the short- and medium-term, even when taking reduced consumption into account. In most countries, tobacco tax revenues are thousands of times higher than tobacco control expenditures.

To maximize the health impact of higher taxes, some revenues should be earmarked for tobacco control and other public health and social programmes. This makes tobacco tax increases even more popular with the public, including tobacco users.

It is also ethically appropriate for governments to use some of the increased tobacco tax revenue to help tobacco users quit through comprehensive tobacco control programmes.

Every country should raise its tobacco taxesIn many countries, cigarette prices have not kept up with increases in the price of other goods and services and increased consumer purchasing power.

Every country can increase its tobacco taxes to reduce smoking, raise funds for tobacco control policies and pay for other public health and social programmes.

Raise taxes on tobaccotax stamps, Russia and Egypt (imported cigarettes).

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tax stamps, the netherlands and Egypt (imported cigarettes).

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tax stamp, Russia.

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