ABSTRACT

This report describes the current status of the tobacco control measures contained in the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022 (Pan American Health Organization) and the advances made in its application, identifying achievements from 2016 to 2020 and challenges that still need to be addressed in order to reach the expected goals. This analysis relied on data from the World Health Organization (WHO) Report on the Global Tobacco Epidemic from 2015, 2017, and 2019, and national regulations were analyzed to determine their consistency with WHO criteria. Significant progress has been made in implementation of the WHO Framework Convention on Tobacco Control in the Americas. By 2020, most countries had regulations on 100% smoke-free environments in indoor public places, workplaces, and public transport, and large graphic health warnings on tobacco packaging. The number of countries that ban tobacco advertising, promotion, and sponsorship and that tax tobacco at the minimum level recommended by WHO has doubled since 2016. However, the 2022 targets have not yet been reached for any of these measures or for ratification of the relevant international agreements. Although progress has been made in the Region, it has not been uniform. Unless the pace of application of the tobacco control measures contained in the Strategy and Plan of Action accelerates, it is unlikely that its targets will be met. Tobacco industry interference remains one of the main challenges.

Keywords
Legislation as topic; tobacco; noncommunicable diseases; public health policy; risk factors; Americas

RESUMEN

Se describe el estado actual y los avances en la aplicación de las medidas de control del tabaco contenidas en la Estrategia y Plan de Acción para Fortalecer el Control del Tabaco en la Región de las Américas 2018-2022 y se identifican los logros alcanzados entre los años 2016 y 2020 y los retos que aún se deben enfrentar para cumplir las metas previstas. Para ello se utilizaron los datos del Informe de la Organización Mundial de la Salud (OMS) sobre la Epidemia Mundial de Tabaquismo de los años 2015, 2017 y 2019, así como las normativas nacionales para determinar su consistencia con los criterios de la OMS. Se constatan importantes avances en la aplicación del Convenio Marco de la OMS para el Control del Tabaco en las Américas. Al 2020, la mayoría de los países contaban con normativas sobre ambientes 100% libres de humo en lugares cerrados públicos y de trabajo, y el transporte público, y advertencias sanitarias gráficas grandes en los paquetes de tabaco. Desde el 2016 se duplicó el número de países que prohíben la publicidad, la promoción y el patrocinio del tabaco y que aplican impuestos al tabaco al nivel mínimo recomendado por la OMS. Sin embargo, aún no se ha alcanzado la meta prevista al 2022 para ninguna de esas medidas ni para la ratificación de los tratados internacionales en el tema. Aunque se ha avanzado en la Región, el avance no ha sido uniforme, y a menos que el ritmo de aplicación de las medidas de control del tabaco contenidas en la Estrategia y Plan de Acción se acelere, es poco probable que se logren las metas establecidas. La interferencia de la industria tabacalera se mantiene como uno de los principales retos.

Palabras clave
Legislación como asunto; tabaco; enfermedades no transmisibles; políticas públicas de salud; factores de riesgo; Américas

RESUMO

Este artigo descreve a situação atual e o progresso na implementação das medidas para o controle do tabagismo prescritas na Estratégia e plano de ação para fortalecer o controle do tabagismo na Região das Américas 2018-2022, reconhece as conquistas realizadas no período entre 2016 e 2020, e identifica os desafios a serem enfrentados para alcançar as metas planejadas. A análise se baseou em dados obtidos do Relatório da OMS sobre a Epidemia Global do Tabaco, publicado em 2015, 2017 e 2019, e em regulamentações nacionais para determinar o cumprimento dos critérios da OMS. Observam-se avanços na implementação da Convenção-Quadro da OMS para o Controle do Tabaco nas Américas. Em 2020, a maior parte dos países dispunha de regulamentações para ambientes 100% livres da fumaça do tabaco em locais públicos fechados, locais fechados de trabalho e meios de transporte público, e advertências sanitárias com ilustrações gráficas grandes nas embalagens dos produtos de tabaco. O número de países que proíbem publicidade, promoção e patrocínio do tabaco e adotaram impostos sobre os produtos do tabaco no padrão mínimo recomendado pela OMS dobrou desde 2016. No entanto, as metas planejadas para 2022 ainda não foram atingidas – tanto em relação a estas medidas quanto à ratificação dos respectivos tratados internacionais. Apesar dos avanços, o progresso na Região não é uniforme. Se as medidas para o controle do tabaco prescritas na Estratégia e plano de ação não forem implementadas em um ritmo acelerado, as metas dificilmente serão alcançadas. A interferência da indústria do tabaco continua sendo um dos maiores desafios.

Palavras chave
Legislação como assunto; tabaco; doenças não transmissíveis; políticas públicas de saúde; fatores de risco; América

Tobacco use is responsible for nearly one million deaths each year in the Region of the Americas (¹1. Institute for Health Metrics and Evaluation. GBD Compare Data Visualization [online database]. Seattle, WA: IHME, University of Washington; 2019. Available at: https://vizhub.healthdata.org/gbd-compare [accessed 16 February 2020].
https://vizhub.healthdata.org/gbd-compar... ) and constitutes the only common risk factor of the four major noncommunicable diseases (NCDs): cardiovascular disease, cancer, chronic respiratory disease, and diabetes. Moreover, it imposes a considerable burden on national economies (²2. Goodchild M, Nargis N, d’Espaignet ET. Global economic cost of smoking-attributable diseases. Tob Control. 2018;27(1):58−64. Available at: https://tobaccocontrol.bmj.com/content/27/1/58?gclid=EAIaIQobChMI1_uTk43u9gIVFp7VCh0ugg6cEAAYASAAEgI19fD_BwE [accessed 30 March 2022].
https://tobaccocontrol.bmj.com/content/2... ) and households—particularly the poorest and most vulnerable (³3. World Health Organization. Tobacco and poverty: a vicious circle. Geneva, CH: WHO; 2004. Available at: https://apps.who.int/iris/handle/10665/68704 [accessed 16 May 2021].
https://apps.who.int/iris/handle/10665/6... )—and on the environment (⁴4. World Health Organization. Tobacco and its environmental impact: an overview. Geneva, CH: WHO; 2017. Available at: https://apps.who.int/iris/handle/10665/255574 [accessed 16 May 2021].
https://apps.who.int/iris/handle/10665/2... ). Considering both the threat to sustainable development posed by the tobacco epidemic and the contribution that tobacco control measures can make to minimizing it, one of the targets of Goal 3 of the United Nations 2030 Agenda for Sustainable Development is to strengthen the implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in all countries (target 3.a) in order to reduce premature mortality from NCDs by one third (target 3.4) by 2030 (⁵5. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. General Assembly of the United Nations, 21 October 2015. New York City: UN; 2015. (Document A/RES/70/1). Available at: https://unctad.org/system/files/official-document/ares70d1_en.pdf [accessed 24 March 2022].
https://unctad.org/system/files/official... ).

The FCTC, which is the first international public health treaty negotiated under WHO auspices, contains effective measures to combat the tobacco epidemic (⁶6. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva, CH: WHO; 2003, updated reprint, 2004, 2005. Available at: https://apps.who.int/iris/bitstream/handle/10665/42811/9241591013.pdf;jsessionid=585B0EF1D1ED3A97754577FB3D76835C?sequence=1 [accessed 26 March 2022].
https://apps.who.int/iris/bitstream/hand... ). Since its entry into force in 2005, the FCTC has energized action on this issue in the Americas, although implementation of its measures has not been uniform. In 2017, a slowdown was observed in implementation of the measures contained in the FCTC (⁷7. Pan American Health Organization. Report on Tobacco Control in the Region of the Americas, 2018. Washington, DC: PAHO; 2018. Available at: https://iris.paho.org/handle/10665.2/49237 [accessed 16 February 2020].
https://iris.paho.org/handle/10665.2/492... ), which led the 35 PAHO Member States of the Pan American Health Organization (PAHO) to unanimously approve the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018–2022 (Strategy and Plan of Action) during the 29th Pan American Sanitary Conference (⁸8. Pan American Health Organization. Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018–2022. Washington, DC: PAHO; 2019. Available at: https://www.paho.org/en/documents/strategy-and-plan-action-strengthen-tobacco-control-region-americas-2018-2022 [accessed 26 March 2022].
https://www.paho.org/en/documents/strate... ).

The Strategy and Plan of Action is aligned with the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 (⁹9. World Health Organization. Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva, CH: WHO; 2013. Available at: https://apps.who.int/iris/handle/10665/94384 [accessed 2 December 2020].
https://apps.who.int/iris/handle/10665/9... ) and the Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas 2013–2019 (¹⁰10. Pan American Health Organization. Plan of Action for the Prevention and Control of Noncommunicable Diseases in the Americas 2013-2019. Washington, DC: PAHO; 2014. Available at: https://iris.paho.org/handle/10665.2/35009 [accessed 24 March 2022].
https://iris.paho.org/handle/10665.2/350... ), as well as with the United Nations 2030 Agenda for Sustainable Development (⁵5. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. General Assembly of the United Nations, 21 October 2015. New York City: UN; 2015. (Document A/RES/70/1). Available at: https://unctad.org/system/files/official-document/ares70d1_en.pdf [accessed 24 March 2022].
https://unctad.org/system/files/official... ). Its overall objective is to accelerate the implementation of the FCTC in the Region, especially the articles referring to the measures that WHO considers to be “best buys”, i.e. the most cost-effective and the most feasible to implement for NCD prevention (¹¹11. World Health Organization. Tackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva, CH: WHO; 2017. Available at: https://apps.who.int/iris/handle/10665/259232 [accessed 30 March 2022].
https://apps.who.int/iris/handle/10665/2... ).

Given the magnitude of the tobacco epidemic and its health, social, and economic implications, it is important to monitor the implementation of tobacco control measures in the Region of the Americas. This study describes the current status and progress in implementing the tobacco control measures contained in the Strategy and Plan of Action — and other related global commitments — at the national level, and identifies the achievements made between 2016 and 2020 and the challenges that still need to be addressed to meet the planned targets.

MATERIALS AND METHODS

The analysis focused on the progress made regarding the four strategic lines of action and the seven objectives contained in the Strategy and Plan of Action (table 1), based on the implementation status of the measures corresponding to each strategic line of action in 2016 and its 10 indicators.

Using this baseline, the progress made as of 30 June 2020 to achieve the goals set for 31 December 2022, as agreed by all PAHO Member States (⁸8. Pan American Health Organization. Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018–2022. Washington, DC: PAHO; 2019. Available at: https://www.paho.org/en/documents/strategy-and-plan-action-strengthen-tobacco-control-region-americas-2018-2022 [accessed 26 March 2022].
https://www.paho.org/en/documents/strate... ), was described.

The analysis also included the progress made since 2016 in the implementation of the two measures of the MPOWER package of effective measures to prevent and reduce tobacco use (¹²12. World Health Organization. MPOWER: a policy package to reverse the tobacco epidemic. Geneva, CH: WHO; 2008. Available at: https://apps.who.int/iris/handle/10665/43888 [accessed 26 March 2022].
https://apps.who.int/iris/handle/10665/4... ) that were not included in the four strategic lines of action of the Strategy and Plan of Action, described in table 2: measure M, related to the monitoring of tobacco use and prevention policies, and measure O, on offering support to quit tobacco use. Although these two measures are not among those considered by the WHO as “best buys”, they reflect two very important aspects that must be considered.

Data sources

Data sources used for this study include the WHO Report on the Global Tobacco Epidemic (Global Report) of 2019 (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ), its previous editions from 2015 (¹⁴14. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2015: raising taxes on tobacco. Geneva, CH: WHO; 2015. Available at: https://apps.who.int/iris/handle/10665/178574 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/1... ) and 2017 (¹⁵15. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2017: monitoring tobacco use and prevention policies. Geneva, CH: WHO; 2017. Available at: https://apps.who.int/iris/handle/10665/255874 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/2... ), the national regulations compiled by the tobacco control team of the PAHO Department of Noncommunicable Diseases and Mental Health, and the United Nations Treaty Collection (¹⁶16. United Nations. Treaty Collection. Depository. Status of treaties. Chapter IX. Health. New York, NY: UN; 2020. Available at: https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&clang=_en [accessed 10 December 2020].
https://treaties.un.org/pages/ViewDetail... ).

The Global Report, published biennially, contains national regulations — including laws, decrees, and resolutions — and official information — such as policies and programs — relating to strategic lines of action 1 and 2 of the Strategy and Plan of Action. This information was collected with structured questionnaires sent to WHO Member States through its regional and country offices. In addition, the PAHO tobacco control team, as part of its technical assistance work, regularly monitors the approval of new regulations on this issue, and changes to existing regulations.

The source of information for the regulations related to strategic line of action 3 was the United Nations Treaties Collection (¹⁶16. United Nations. Treaty Collection. Depository. Status of treaties. Chapter IX. Health. New York, NY: UN; 2020. Available at: https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-4&chapter=9&clang=_en [accessed 10 December 2020].
https://treaties.un.org/pages/ViewDetail... ). At the time of the analysis, no information was available regarding strategic line of action 4. The collection of this data is being finalized in 2021 as part of the process of preparing the 2021 Global Report (¹⁷17. Pan American Health Organization. Progress Reports on Technical Matters: B. Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018-2022: Midterm Review. Washington, DC: PAHO; 2020. (CD58/INF/14). Available at: https://www.paho.org/en/documents/cd58inf14-progress-reports-technical-matters-b-strategy-and-plan-action-strengthen [accessed: 26 March 2022].
https://www.paho.org/en/documents/cd58in... ).

Data analysis procedures

The criteria for assessing whether actions taken follow WHO criteria are set out in the technical notes to the 2019 Global Report (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ). For the present evaluation, national regulations were reviewed by at least two tobacco control experts; in the case of the Americas, one expert was from WHO headquarters and another from the PAHO tobacco control team. Regarding tobacco use surveillance and monitoring surveys, only those having national representativeness were considered.

As to regulations on 100% smoke-free environments, in the cases of federative countries, not only national regulations but also subnational regulations (corresponding to the first level of government below the national level) were considered, provided that they covered at least 90% of the country’s total population.

EVALUATION RESULTS

The results are presented according to the progress made towards: 1. achieving the goals established for each of the strategic lines of action in the Strategy and Plan of Action (table 3; see figure 1 to better visualize the results and more easily compare the indicators); and 2. implementing the M and O measures of the MPOWER package (table 4).

Strategic line of action 1

The target for indicator 1.1.1 is that by the end of 2022 all 35 PAHO Member States will have established 100% smoke-free environments in enclosed public and work spaces, and on public transportation. As of June 30, 2020, 22 countries (covering approximately 50% of the Region’s population) had reached this goal, with four countries signing on since 2016.

For indicator 1.2.1, the target for 2022 is for all 35 PAHO Member States to have implemented health warnings covering at least 50% of the principal display areas of cigarette packs and meeting other appropriate standards (¹⁹19. World Health Organization. Guidelines for Implementation of the WHO FCTC: Article 5.3, Article 9, articles 9 and 10, Article 11, Article 12, Article 13, Article 14. Geneva, CH: WHO; 2013. Available at: https://www.who.int/fctc/treaty_instruments/adopted/guidel_2011/en/ [accessed 26 March 2022].
https://www.who.int/fctc/treaty_instrume... ). As of 30 June 2020, 21 countries (56% of the Region’s population) had reached this goal, with five new countries since 2016.

Regarding indicator 1.2.2, the target for 2022 is for six countries to have adopted either a single presentation of each brand (allowing only one variant to be sold per brand) or plain packaging of tobacco products (banning the use in packaging of logos, colors, brand images or promotional information other than the brand name and product name in a standard color and font) (²⁰20. World Health Organization. Plain packaging of tobacco products: evidence, design and implementation. Geneva, CH: WHO; 2017. Available at: https://apps.who.int/iris/bitstream/handle/10665/207478/9789241565226_eng.pdf?sequence=1&isAllowed=y [accessed 26 March 2022].
https://apps.who.int/iris/bitstream/hand... ). As of 30 June 2020, two countries (6.5% of the Region’s population) had already implemented plain packaging, and since 2016 one of them had also implemented single presentation policy.

Strategic line of action 2

The target for indicator 2.1.1 is that by the end of 2022, 20 countries will have implemented a total ban on tobacco advertising, promotion, and sponsorship. As of 30 June 2020, eight countries (30% of the Region’s population) had met the target, with the addition of three countries since 2016.

For indicator 2.1.2, the target for 2022 is for 19 countries to have banned the display of tobacco products at points of sale (allowing only textual listing of products and their prices, without any promotional elements) (¹⁹19. World Health Organization. Guidelines for Implementation of the WHO FCTC: Article 5.3, Article 9, articles 9 and 10, Article 11, Article 12, Article 13, Article 14. Geneva, CH: WHO; 2013. Available at: https://www.who.int/fctc/treaty_instruments/adopted/guidel_2011/en/ [accessed 26 March 2022].
https://www.who.int/fctc/treaty_instrume... ). Eight countries (9% of the Region’s population) had met the target as of 30 June 2020, with four countries having done so since 2016.

Regarding indicator 2.2.1, the target for 2022 is for there to be 10 countries in which total indirect taxes represent 75% or more of the final retail price of the most-sold brand of cigarettes in the country, or in which the increase in the share of total taxes in the final retail price has been substantial enough to promote a change of category in the tax burden on cigarettes, according to the thresholds set for the measure in the 2019 Global Report (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ). According to the latest available data, as of 31 July 2018, five countries (32% of the Region’s population) had met the target, with the addition of three countries since 2016.

For 2022, the target of indicator 2.2.2 is for 20 countries to have raised their excise taxes in such a way as to relative decrease the affordability of cigarettes by 10% or more compared to their affordability in 2014, according to the affordability index presented in the 2015 Global Report.

This index is defined as the percentage of per capita gross domestic product that is needed to purchase 100 packs of the most-sold brand; the higher the index value, the less affordable cigarettes are (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ). According to the available data, as of 31 July 2018, 11 countries (22.5% of the Region’s population) had met the target.

Strategic line of action 3

The target for indicator 3.1.1 is that by the end of 2022, 33 countries will have ratified the FCTC. As of 30 June 2020, 30 countries (60% of the Region’s population) had ratified it, although none since 2016.

Regarding indicator 3.2.1, the target for 2022 is for 20 States Parties to the FCTC to have also ratified the Protocol to Eliminate Illicit Trade in Tobacco Products (²¹21. World Health Organization. Protocol to eliminate illicit trade in tobacco products. Geneva, CH: WHO; 2013. Available at: https://apps.who.int/iris/handle/10665/80873 [accessed 26 March 2022].
https://apps.who.int/iris/handle/10665/8... ). As of 30 June 2020, six countries (25% of the Region’s population) had ratified the Protocol, with the accession of two countries since 2016.

Strategic line of action 4

The target for indicator 4.1.1 by 2022 is for 20 countries to have mechanisms for identifying and managing conflicts of interest for government officials and employees with responsibilities for tobacco control policies (¹⁹19. World Health Organization. Guidelines for Implementation of the WHO FCTC: Article 5.3, Article 9, articles 9 and 10, Article 11, Article 12, Article 13, Article 14. Geneva, CH: WHO; 2013. Available at: https://www.who.int/fctc/treaty_instruments/adopted/guidel_2011/en/ [accessed 26 March 2022].
https://www.who.int/fctc/treaty_instrume... ). In June 2021, there was still no information available on developments regarding this indicator.

MPOWER MEASURE M

According to the information available as of 31 July 2018, 11 of the 35 countries in the Region (65% of the population) met all the requirements of best practices in tobacco consumption monitoring and prevention policies, according to WHO criteria; since 2016, one additional country has done so (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ).

MPOWER MEASURE O

Regarding the offer of help to quit tobacco use, the latest available information corresponds to the 2019 Global Report, according to which six countries in the Region of the Americas (73% of the population) maintained the highest level of application of best practices according to WHO criteria, one country less than in 2016 (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ).

ACHIEVEMENTS IN THE REGION

Since the adoption of the Strategy and Plan of Action, major progress has been made in the implementation of the FCTC in the Region of the Americas. In particular, significant—though uneven—progress has been observed in recent years in the non-Spanish-speaking Caribbean subregion. Antigua and Barbuda, Guyana, and Suriname adopted tobacco control regulations such as requiring smoke-free environments and appropriate packaging and labelling of tobacco products, and enacting a complete ban on tobacco advertising, promotion, and sponsorship—measures consistent with Articles 8, 11, and 13 of the FCTC. However, non-Spanish-speaking Caribbean countries continue to lag behind in other important areas: for example, six of these 14 countries have yet to adopt any measures from the MPOWER package at the best practices level, according to WHO criteria.

Progress has also been noted in the South American countries during the period under review. In 2018, Brazil became the second country in the world—after Turkey—to apply all six measures of the MPOWER package at the best practices level. This represents a major achievement, because the positive impact of tobacco control measures is more powerful when they are implemented together, as originally conceived in the FCTC. Due to the gradual implementation of measures at the best practices level in Brazil since 2002, the country has seen a decline in the prevalence of cigarette smokers in its capital cities, from 15.6% in 2007 to 9.8% in 2019 (²²22. Federative Republic of Brazil, Ministry of Health. Vigitel Brazil 2019: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2019 (Vigitel Brazil 2019: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates on the frequency and sociodemographic distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2019). Brasília: Ministry of Health; 2020. Available at: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2019_vigilancia_fatores_risco.pdf [accessed 2 December 2020].
http://bvsms.saude.gov.br/bvs/publicacoe... ). Likewise, with the adoption in Bolivia of the law requiring 100% smoke-free environments in all closed public and work spaces and on public transport, and the approval by Paraguay of an amendment to its tobacco control law (which is not counted in the results of the present analysis because it occurred after the cut-off date for data collection), South America became a 100% smoke-free subregion in 2020. Despite these advances, compliance with the regulations remains a challenge: as reflected in the 2019 Global Report, a qualitative assessment by national experts showed that the average level of compliance is moderate in 20 countries (¹³13. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2019: offer help to quit tobacco use. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/326043 [accessed 1 December 2020].
https://apps.who.int/iris/handle/10665/3... ).

In the case of North American countries, a significant advance has been the approval of plain packaging of tobacco products in Canada, a country that joins Uruguay in leading on this issue.

Partly due to all these advances in the implementation of tobacco control measures in the countries of the Region, according to WHO estimates—and unlike forecasts at the global level—the Region of the Americas is on track to reach the goal proposed in the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 of achieving a relative decrease of 30% in the prevalence of consumption of tobacco in adults by 2025 (²³23. World Health Organization. WHO Global Report on Trends in Prevalence of Tobacco Smoking 2000-2025. 2nd ed. Geneva, CH: WHO; 2019. Available at: https://apps.who.int/iris/handle/10665/272694 [accessed 29 March 2022].
https://apps.who.int/iris/handle/10665/2... ). Moreover, given that tobacco use is the most policy-responsive of targeted risk factors for NCDs, countries in the Region could contribute even more significantly to reducing the prevalence and premature mortality of NCDs worldwide if they achieved relative reductions above 30% (²⁴24. Kontis V, Mathers CD, Rehm J, Stevens GA, Shield KD, Bonita R, et al. Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study. Lancet. 2014;384(9941):427−37. Available at: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2814%2960616-4 [accessed 29 March 2022].
https://www.thelancet.com/action/showPdf... ).

CHALLENGES AND OUTLOOK

Despite the progress described in this report, unless the pace of implementation of the tobacco control measures contained in the Strategy and Plan of Action accelerates, the 2022 targets are unlikely to be achieved in the Region of the Americas.

The measure aimed at implementing a total ban on tobacco advertising, promotion, and sponsorship remains among the least applied measures in the Region. Moreover, even though tobacco taxation is the most cost-effective measure to reduce tobacco consumption (²⁵25. International Agency for Research on Cancer. Effectiveness of tax and price policies for tobacco control. IARC Handbooks of Cancer Prevention. Vol. 14. Lyon, France: IARC; 2011. Available at: https://publications.iarc.fr/Book-And-Report-Series/Iarc-Handbooks-Of-Cancer-Prevention/Effectiveness-Of-Tax-And-Price-Policies-For-Tobacco-Control-2011 [accessed 10 November 2020].
https://publications.iarc.fr/Book-And-Re... ), it remains widely underutilized in the Region. This is largely explained by interference from the tobacco industry, which seeks to prevent the implementation of such measures on the grounds that raising excise taxes on tobacco products necessarily leads to increased illicit trade in these products. In fact, the evidence shows that taxes and prices have a limited impact on illicit trade, and that other factors—such as those related to the governance and control of the tobacco products supply chain—are among the main determinants of this phenomenon (²⁶26. U.S. National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control. National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016. Available at: https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-21 [accessed 10 November 2020].
https://cancercontrol.cancer.gov/brp/tcr... , ²⁷27. World Bank. Confronting Illicit Tobacco Trade: A Global Review of Country Experiences. Washington, DC: WB; 2019. Available at: https://documents.worldbank.org/en/publication/documents-reports/documentdetail/677451548260528135/confronting-illicit-tobac-co-trade-a-global-review-of-country-experiences [accessed 10 November 2020].
https://documents.worldbank.org/en/publi... ). In addition, robust, transparent, independent studies measuring the volume of illicit cigarette trade in the Region have found that the figures used by the tobacco industry tend to be overestimates (²⁸28. Paraje G. Illicit cigarette trade in five South American countries: a gap analysis for Argentina, Brazil, Chile, Colombia, and Peru. Nicotine Tob Res. 2019;21(8):1079−86.

29. Maldonado N, Llorente BA, Iglesias RM, Escobar D. Measuring illicit cigarette trade in Colombia. Tob Control. 2020;29(Suppl 4):s260−6.-³⁰30. De Miera Juarez BS, Reynales-Shigematsu LM, Stoklosa M, Welding K, Drope J. Measuring the illicit cigarette market in Mexico: a cross validation of two methodologies. Tob Control. 2021;30(2):125−31.). The Protocol to Eliminate Illicit Trade in Tobacco Products is the best response to illegal trade in these products (²¹21. World Health Organization. Protocol to eliminate illicit trade in tobacco products. Geneva, CH: WHO; 2013. Available at: https://apps.who.int/iris/handle/10665/80873 [accessed 26 March 2022].
https://apps.who.int/iris/handle/10665/8... ), and its ratification is a challenge in itself: only six countries in the Region have signed, with little progress in recent years.

Another obstacle to progress in the implementation of the FCTC in many countries is the absence of measures to neutralize the tobacco industry’s attempts to interfere, delay, hinder, or impede the implementation of tobacco control measures aimed at protecting the health of the population. Greater and more sustained efforts should also be devoted to monitoring, documenting, and publicizing the tobacco industry’s activities, highlighting its obstructive strategies, and adopting legal instruments to address potential conflicts of interest among officials involved in tobacco control.

Closely linked to this is the challenge of redoubling efforts towards establishing national coordinating mechanisms for tobacco control—in line with Article 5.2 of the FCTC—that are adequately financed and that enable consistency between health policies and tax, commercial, agricultural, educational, and any other policies necessary to provide an effective and comprehensive response to the tobacco epidemic.

Another cross-cutting challenge facing the Region is to strengthen technical capacity at the national level, aimed at conducting research and generating evidence to support national policies and, most importantly, to reverse the obstructive arguments of the tobacco industry and its allies (³¹31. Sandoval RC, Belausteguigoitia I, Hennis A. El caso de los impuestos al tabaco: dónde nos encontramos y cómo acelerar su uso a favor de la salud pública (The case of tobacco taxation: where we are and how to accelerate its use for public health.). Rev Panam Salud Publica. 2016;40(4):200−1. Available at: https://iris.paho.org/bitstream/handle/10665.2/31299/v40n4a02-spa.pdf?sequence=5&isAllowed=y [accessed 2 April 2022].
https://iris.paho.org/bitstream/handle/1... ). In this regard, it is important to continue promoting South-South cooperation, as well as knowledge-sharing among countries at regional and subregional forums.

All these challenges have become even more urgent in the context of COVID-19. There are reports that the tobacco industry has taken advantage of the pandemic to step up promotion of its products, as well as efforts to position itself as a valid interlocutor in public policy debate (³²32. Stopping Tobacco Organizations and Products. An open letter to the Secretary-General of the United Nation; 2020. Available at: https://exposetobacco.org/wp-content/uploads/Update-Open-Letter-to-UN-Sec-Gen-re-Misinformation_30-April-2020_hyperlinked.pdf [accessed 22 December 2020].
https://exposetobacco.org/wp-content/upl... ). Meanwhile, the available evidence indicates that smokers and people with NCDs are at higher risk of becoming seriously ill and dying if they contract COVID-19 (³³33. Pan American Health Organization. NCDs and COVID-19 [website]. Washington, DC. PAHO; 2020. Available at: https://www.paho.org/en/ncds-and-covid-19 [accessed 30 March 2022].
https://www.paho.org/en/ncds-and-covid-1... , ³⁴34. World Health Organization. Smoking and COVID-19: scientific brief, 30 June 2020. Geneva, CH: WHO; 2020. Available at: https://apps.who.int/iris/handle/10665/332895 [accessed 14 September 2020].
https://apps.who.int/iris/handle/10665/3... ).

In the context of the pandemic, adopting forceful policies to confront attempts at interference by the tobacco industry cannot be delayed any further, and it is essential to achieve fluid interaction between the different sectors of government involved in the different areas of tobacco control, through prompt implementation of the national coordinating mechanisms in the FCTC. The difficult health situation created by COVID-19, in which countries may need additional resources to respond to the pandemic, could bring to the fore the role of taxes on unhealthy products—such as tobacco products—in economic recovery plans, as they constitute an additional and immediate source of tax revenue. Moreover, this situation may open an opportunity to strengthen tobacco cessation support services at the first level of care, as part of a transformation in the approach to NCDs and their risk factors arising from the pandemic. Finally, surveillance systems could be strengthened to conduct research on how COVID-19 has impacted the tobacco epidemic, among other important issues.

CONCLUSIONS

Implementation of the FCTC continues to advance in the Region of the Americas, and in recent years significant progress has been made in the non-Spanish-speaking Caribbean, South America, and North America; however, achievements have been very limited in the countries of Central America and the Spanish-speaking Caribbean. Moreover, it is striking that despite this progress in the non-Spanish-speaking Caribbean, this remains the subregion where the implementation level of effective measures is lower than expected.

By 2020, most countries had 100% smoke-free environments in enclosed public and work spaces and public transportation, as well as large health warnings on tobacco packages. However, the Region is far from the target set for 2022, even though a great many of these measures fall under the exclusive responsibility of the health sector.

While the number of countries implementing the ban on advertising, promotion, and sponsorship did rise, as did those promoting higher taxes on tobacco products that meet WHO minimum recommendations, the reality is that the target set for the end of 2022 is still far from being reached. There was also a minimal change in the number of countries monitoring tobacco use, and a slight decline in those offering help to quit. Since 2016 no country has ratified the FCTC, and only two have ratified the Protocol to Eliminate Illicit Trade in Tobacco Products.

If the current pace of progress in the implementation of tobacco control measures holds steady, it is unlikely that the targets of the Strategy and Plan of Action will be achieved in 2022. Tobacco industry interference remains one of the major obstacles, particularly during the COVID-19 pandemic, which has made smokers and people with NCDs more vulnerable. However, the current pandemic situation also creates an opportunity and an obligation to redouble efforts in the fight against the tobacco epidemic, and to contribute to achieving the goals of the 2030 Agenda for Sustainable Development in the Region of the Americas.

Declaration.

The opinions expressed in this article are the responsibility of the authors and do not necessarily reflect the opinions, policies, or official positions of the institutions to which they are affiliated, nor the criteria or policy of the Pan American Journal of Public Health and/or the Pan American Health Organization.

Acknowledgements.

The authors would like to thank current and past members of the PAHO Department of Noncommunicable Diseases and Mental Health for their valuable contributions to the development and monitoring of the Strategy and Plan of Action to Strengthen Tobacco Control in the Region of the Americas 2018–2022, especially Adriana Blanco, Anselm Hennis, Ramón Martínez, Roberta Caixeta, Kavita Singh, and Itziar Belausteguigoitia. Special thanks to all the officials of the ministries of Health and ministries of Finance of Latin America and the Caribbean who participated in the data collection that served to prepare the current and past versions of the WHO Report on the Global Tobacco Epidemic, and also to the tobacco control focal points of the PAHO/WHO country offices and WHO headquarters.

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