Moving forward in the Americas: tobacco control fosters sustainable development

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 IGO License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited. No modifications or commercial use of this article are permitted. In any reproduction of this article there should not be any suggestion that PAHO or this article endorse any specific organization or products. The use of the PAHO logo is not permitted. This notice should be preserved along with the article’s original URL. Open access logo and text by PLoS, under the Creative Commons Attribution-Share Alike 3.0 Unported license. 1 Head of the Secretariat of the WHO Framework Convention on Tobacco Control, Geneva, Switzerland 2 Director of International Policy Education in Addictions, Annenberg Physician Training Program at the Ulrich and Ruth Frank Foundation for International Health, Montevideo, Uruguay 3 Director de Investigación y Profesor Titular, Escuela de Negocios, Universidad Adolfo Ibanez, Santiago de Chile, Chile; Millennium Nucleus for the Evaluation and Analysis of Drug Policies (nDP), Santiago de Chile, Chile. 4 Project Officer for the Tobacco Free Initiative, World Health Organization, Geneva, Switzerland 5 Public Health Advisor, Bloomberg Philanthropies, New York, New York, United States of America 6 Associate Director, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America. The World Health Organization (WHO) estimates that 1.3 billion people in the world aged 15 years and older consume tobacco, of which 128 million (10%) live in the Region of the Americas. Since 2000, when WHO estimates started, the number of tobacco users in the Americas has reduced by 22.4%, from 165 million to 128 million users, even with concurrent population growth. Despite this progress, without additional tobacco control actions, the current projection by 2025 is that around 118 million people will still be using tobacco in the Americas (1). Cigarettes are the most consumed tobacco product among men and women in the Americas. Around 92% of tobacco users in the Region smoke tobacco (90% of males and 96% of females), and among them, around 91% use cigarettes (manufactured or roll-your-own) (1). All WHO regions, on average, present a decline in age-standardized tobacco-use prevalence rates among adults. However, the Region of the Americas shows the fastest decline, putting it on track to reducing prevalence by 30% or more by 2025 (from a 2010 baseline), a voluntary target set under the Global Action Plan on the Prevention and Control of Noncommunicable Diseases (2). Additionally, among males, the average prevalence in the Americas is also declining faster than in any other region, making it the only WHO Region on track for a relative reduction of 31% for this group by 2025, down from a prevalence of 27.4% in 2010 to 18.9% in 2025. Despite the Region of the Americas having the second highest prevalence rate of tobacco use among females (11.3%), placing it only behind the European Region (17.7%), the average prevalence is on track for reaching a relative reduction of 35% by 2025, down from 15.2% in 2010 to 9.8% in 2025. However, the decline in this group in the Region is slower than the global average of a relative reduction of 41%, and the projected rate for the Region in 2025 is also higher than the projected global average prevalence among women of 6.6%. Notwithstanding the remarkable downward trend in prevalence rates in adults in the Americas, the progress within the Region and in countries varies widely. Fifteen countries out of 35 (43%) are on track to reduce prevalence by 30% or more by 2025. However, in 11 out of 35 (31%), the trend is unknown because these countries do not have sufficient data to calculate tobacco use trend estimates. The proportion of countries in the Region that lack the necessary data to model trends in tobacco-use prevalence is the worst amongst all WHO regions. (1). Regarding current tobacco use among adolescents, WHO's latest estimates indicate that at least 5.2 million adolescents aged 13–15 years in the Americas are current users of some form of tobacco–2.8 million boys and 2.4 million girls. This represents an average prevalence rate of 11.3%, which is higher

The World Health Organization (WHO) estimates that 1.3 billion people in the world aged 15 years and older consume tobacco, of which 128 million (10%) live in the Region of the Americas. Since 2000, when WHO estimates started, the number of tobacco users in the Americas has reduced by 22.4%, from 165 million to 128 million users, even with concurrent population growth. Despite this progress, without additional tobacco control actions, the current projection by 2025 is that around 118 million people will still be using tobacco in the Americas (1). Cigarettes are the most consumed tobacco product among men and women in the Americas. Around 92% of tobacco users in the Region smoke tobacco (90% of males and 96% of females), and among them, around 91% use cigarettes (manufactured or roll-your-own) (1).
All WHO regions, on average, present a decline in age-standardized tobacco-use prevalence rates among adults. However, the Region of the Americas shows the fastest decline, putting it on track to reducing prevalence by 30% or more by 2025 (from a 2010 baseline), a voluntary target set under the Global Action Plan on the Prevention and Control of Noncommunicable Diseases (2). Additionally, among males, the average prevalence in the Americas is also declining faster than in any other region, making it the only WHO Region on track for a relative reduction of 31% for this group by 2025, down from a prevalence of 27.4% in 2010 to 18.9% in 2025. Despite the Region of the Americas having the second highest prevalence rate of tobacco use among females (11.3%), placing it only behind the European Region (17.7%), the average prevalence is on track for reaching a relative reduction of 35% by 2025, down from 15.2% in 2010 to 9.8% in 2025. However, the decline in this group in the Region is slower than the global average of a relative reduction of 41%, and the projected rate for the Region in 2025 is also higher than the projected global average prevalence among women of 6.6%.
Notwithstanding the remarkable downward trend in prevalence rates in adults in the Americas, the progress within the Region and in countries varies widely. Fifteen countries out of 35 (43%) are on track to reduce prevalence by 30% or more by 2025. However, in 11 out of 35 (31%), the trend is unknown because these countries do not have sufficient data to calculate tobacco use trend estimates. The proportion of countries in the Region that lack the necessary data to model trends in tobacco-use prevalence is the worst amongst all WHO regions. (1).
Regarding current tobacco use among adolescents, WHO's latest estimates indicate that at least 5.2 million adolescents aged 13-15 years in the Americas are current users of some form of tobacco-2.8 million boys and 2.4 million girls. This represents an average prevalence rate of 11.3%, which is higher than the global average prevalence of 10.3% (1). Another crucial point to note among this population is the consumption of electronic cigarettes, which deserves attention considering data from national school-based surveys. More detailed analyses are still required; however, it can be observed that the proportion of adolescents consuming these products is very close to or already higher than the prevalence of current cigarette smoking in at least 15 countries (3).
Further, along with electronic cigarettes, another product very attractive to young people are cigarettes with flavored capsules. The presence of these products is problematic given their appeal among youths and their potential to evade country bans on flavored tobacco products, if those laws are not comprehensive enough, particularly in low and middle-income countries where they hold a larger market share (4,5). In recent years, there has also been a growth of flavored non-cigarette products in the market, such as electronic cigarettes (like MODs and PODs) (6) and cigars (7), creating new cohorts of nicotine and tobacco users and putting a new generation of youths at risk of nicotine addiction and the severe consequences of tobacco use. Monitoring and researching these products are crucial to determine the role that they play -and the danger that they pose-in the pattern of consumption of tobacco and nicotine products among youths.
The Region of the Americas shows some unique traits: although it presents the fastest declines, it is also the Region with the largest percentage of countries not monitoring the tobacco epidemic. Besides, it also shows prevalence rates above the global averages among the female adult and adolescent populations.
Against this background, this special issue of the Pan American Journal of Public Health presents relevant, up-to-date data from the Region of the Americas, guiding a path where there is still much work to do to improve tobacco control measures. In addition, the multiple research initiatives described in this issue demonstrate the enormous capacity and collaboration that exists in the Region. This special issue is possible due to the cooperation of researchers, national and international organizations, intergovernmental bodies, tobacco control focal points in Ministries of Health, and different specialists in tobacco control that continuously collaborate to achieve health goals.
This thematic issue offers research on key tobacco control policies already achieved in line with the WHO Framework Convention on Tobacco Control (WHO FCTC) (8) and the main challenges ahead. It also describes policy options that can guide governments towards the end of tobacco, transforming the tobacco endgame from a theoretical concept to a concrete and achievable goal.
The highlighted achievements mainly focus on smoke-free environments and health warnings on tobacco products packaging. For instance, the entire subregion of South America and many other countries in the Americas have adopted comprehensive smoke-free policies, and 22 Pan American Health Organization (PAHO) Member States have adopted regulations making it compulsory to include large graphic health warnings on tobacco product packaging, in line with the WHO FCTC (3). However, the current legal and political context in the Region differs from country to country, presenting some measures that are more robust than others. Additionally, future research should examine enforcement issues for an appropriate implementation of these comprehensive measures.
On the other hand, the total ban on tobacco advertising, promotion and sponsorship; taxation; and the implementation of plain packaging remain among the least widely implemented WHO FCTC measures in the Region (3,9). This thematic issue addresses this gap by presenting regional evidence on the effectiveness of the measures mentioned above. This gap is mainly explained due to tobacco and related industries' constant efforts to weaken, delay, and block the implementation of measures consistent with the WHO FCTC and its guidelines. The Parties to the WHO FCTC have indicated that the greatest obstacle to implementing its measures is tobacco industry interference (10). In line with this, this thematic issue also refers to the state of application of mechanisms for the identification and management of conflicts of interest for government officials and employees with responsibility for tobacco control policies in countries, under the framework of PAHO's Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (10). As highlighted by the guidelines for implementing article 5.3 of the WHO FCTC, there is an inherent and irreconcilable conflict between the tobacco industry's interests, and public health policy interests.
Another significant challenge that the Region has faced in recent years has been the introduction of novel and emerging nicotine and tobacco products in the market, such as heated tobacco products (HTPs) and electronic cigarettes (3,6). This special issue describes how tobacco and related industries use media to promote the spread of misleading information about these products to the public, how this marketing is associated with the social acceptability of these products, and the impact of conflict of interest in vaping articles. Besides, it addresses how these products could undermine efforts to denormalize and reduce tobacco use if left unregulated. (3).
Manuscripts are not only focused on health consequences since several of them also highlight the significant social, economic, and environmental impact of tobacco use as well as the economic benefits of tobacco control. Tobacco use leads to increased healthcare expenditure and causes significant productivity losses, burdening households, health systems, and society at large. Significantly, it increases the risk of developing severe disease and death from COVID-19. This special issue presents evidence that quantifies the cost of inaction and, on the opposite end, models the health and economic benefits via a return-on-investment analysis of implementing select WHO FCTC tobacco control measures. These studies highlight how the benefits of investments in tobacco control, particularly in the long-term, are projected to outweigh the costs of implementation and enforcement of selected interventions. Such findings have the potential to help foster policy coherence and advance the all-of-government, all-of-society approach required to tackle tobacco use comprehensively. The lack of such an approach, combined with tobacco industry interference, present a significant barrier for the Region to accelerate advancement in tobacco control measures.
Tobacco use also has implications for sustainable development. Indeed, it threatens the achievement of the Sustainable Development Goals (11), including by accruing losses of human capital; deepening of poverty, hunger and inequality; and damaging the environment. On the other end, the human rights protected by the WHO FCTC -including the rights to life, health, work, a healthy environment, and youths' right to live and grow in such an environment (12)-can spur sustainable development.
This special issue applies this lens, bringing an equity focus to tobacco control measures, with particular attention paid to vulnerable groups (e.g., youth and low-income quintiles) and including a gender perspective. Further, one analysis emphasizes the extent of environmental damage posed across the tobacco production chain, including the economic cost of tobacco products waste, and proposes policies to address this.
Effective tobacco taxation has long been recognized as highly cost-effective and a core part of any comprehensive approach to reducing tobacco use, and particularly in the context of the economic upheaval caused by COVID-19, it presents a strategic opportunity for countries to build back more robust health systems and public finances. This special issue covers several dimensions of tobacco taxation, including an approach for HTPs and electronic cigarettes. It provides an update on the status of tobacco taxation policies in the Region since 2016 and examines the key lessons learned from this extensive experience, as well as how these can be applied for taxing other health-harming products considered drivers of the noncommunicable disease epidemic. It also contributes to the body of evidence on the effectiveness of tobacco taxation policies, with one study looking at the health and economic impact of raised prices of tobacco products due to increased tobacco taxes.
As highlighted earlier, tobacco industry interference remains a major obstacle in implementing tobacco control measures. A common theme adhered to by the industry has to do with the supposed harm that certain tobacco control measures have on local economies. This special issue brings forth independent evidence to debunk these claims, including a study showing that comprehensive smoke-free legislation has no impact on the tourism industry in some countries of the Caribbean community, and an overview of the literature of independent estimates of illicit cigarette trade in Latin America. Such independent evidence should strengthen Member States' capacity to tackle harmful industry interference.
To conclude, this broad collection of manuscripts with a comprehensive approach encompassing the devastating health, social, environmental, and economic consequences of tobacco and nicotine consumption aims to provide a sound basis for building knowledge in the Region of the Americas. We hope that the scientific evidence presented encourages regional actors to implement strong measures and support further research in the local contexts.

Conflicts of interest. None declared.
Disclaimer. Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or those of the Pan American Health Organization (PAHO), the Parties to the WHO Framework Convention on Tobacco Control (WHO FCTC), the Parties to the Protocol to Eliminate Illicit Trade in Tobacco Products (the Protocol), or the Secretariat of the WHO FCTC and its Protocols.