Prioritizing tobacco control & its cessation under sustainable development goals with a focus on India

There is an urgent need to highlight facilitation by the United Nations (UN) to strengthen the control of tobacco along with its cessation as it shall begin reviewing the progress made on sustainable development goals (SDGs) this year. It appears logical to do so because annually world over eight million deaths occur due to tobacco use1. In addition, the global and economic costs due to tobacco-related diseases of 1.4 trillion USD (119,784 billion INR) are not only staggering but also draining away the resources, which could be invested in fulfilment of the agenda of 2030 for sustainable development2,3.

Unlike the millennium development goals (MDGs), which could not achieve equitable progress, the SDGs have envisioned building vibrant and systematic partnerships, which aim to uplift the poor, eliminate hunger and protect human rights, especially of the children while ensuring healthy lives and achievement of overall inclusive, equitable and sustainable development by all countries4,5.

The Sustainable Development Goals (SDGs) and Tobacco Control

The third SDG has the principal objective of maintaining healthy lives along with the promotion of well-being at all ages. Furthermore, it has a direct relationship with people, their dignity, prosperity, partnership and the environment in which they live4,6-8. Hence, very appropriately amongst all four sub-points of SDG 3, namely: (i) strengthening implementation of the Framework Convention on Tobacco Control (FCTC) (WHO FCTC; the SDG target 3.a)1,4,9; (ii) supporting to research and development of vaccines and medicines; (iii) substantial increase in financing health and to retain suitable, capable and empowered human resource8, and (iv) strengthening of management of health risks, it prioritized sub-point 1 on the WHO FCTC, predominantly due to an epidemic impact of tobacco globally and its significant causal relationship with non-communicable disease (NCD) occurrence and prevention8,10. It also merits a high priority on account of tobacco industries violating human rights by enticing children and minors to consume this addictive product11 that gets sold legally despite killing half of its customers1.

The WHO FCTC is the maiden evidence based treaty that provides a regulatory mechanism to the member countries to address the demand- and supply-reduction measures of addictive tobacco. Its secretariat recognizes tobacco control (TC) as an integral part of the development agenda that contributes not only to SDG 3 but also to the achievement of other targets under the SDGs that are directly or indirectly impacted by tobacco growth and use9. The WHO South East Asia Regional Office (SEARO) has categorized the relationship of tobacco with 12 SDGs4.

While SDG 3 addresses tobacco, although indirectly only, through its (i) target 3.a in all member countries as appropriate and (ii) target 3.4 to reduce mortality due to NCDs by one third by 2030, the remaining five goals12 too should be addressing tobacco, preferably directly, due to the following reasons:

(i) It imposes poverty on ~80 per cent of smokers and over 80 per cent of users of smokeless tobacco (SLT) of the world who are in low- and middle-income countries (LMICs) (Goal 1); and

(ii) Strengthening implementation through global partnership for sustainable development needs the promotion of collaborative efforts between government and the non-governmental organizations (NGOs; Goal 17).

While the United Nations (UN) had set out an ambitious target to reduce tobacco use by 30 per cent by 20304, it is intriguing how the high-burden countries such as India and Indonesia will achieve it, especially when there is a likelihood of the current target falling short by at least seven per cent despite a reduction in number of tobacco users by ~60 million between 2000 and 20188.

Taking up India as a case study, two recently released reports on SDGs13,14 were reviewed. While the voluntary network report (VNR) from NITI Aayog, the Government of India (GoI)13, stated that the risk of death from NCDs remained high at 18 per cent, the report made by the Ministry of Statistics and Programme Implementation (MoSPI) in its version 3.0 on SDGs for the National Indicator Framework had no mention of NCDs including tobacco10.

Further, India is yet to have a full coordination in terms of working by an inter-ministerial task force to address and support TC. It cannot be seen entirely as an issue to be addressed by the Ministry of Health and Family Welfare (MoHFW) while other major stakeholder ministries such as Finance, Commerce, Agriculture and Labour are in production, sale or export of tobacco either specifically or as part of their usual operational conduct. Undoubtedly, the process of TC is yet to be fully effective in India to make a major dent in reducing tobacco-related illnesses and deaths.

Worth noting is the anomaly that the tobacco issue was not mentioned by the United Nations General Assembly (UNGA) while deliberating on the World Drug Problem15. However, it has an analogy in India too wherein the GoI had acted similarly while framing the NDPS Act of 198516, which omitted the inclusion of tobacco despite its established addictive property. Therefore, we maintain that the UNGA could consider mentioning tobacco under the SDG target 3.a specifically as the topmost substance abuse to be addressed on priority and within a specified timeline; and the timeline should be no longer than another decade as even within this period our world will lose over 80 million lives. Therefore, at the national level too, it appears appropriate for the MoHFW to coordinate and collaborate with the other stakeholder ministries such as Finance, Commerce, Agriculture, Women & Child Development and the Ministry of Statistics and Program Implementation (MoSPI) through sustained efforts to focus afresh its priorities under SGD 3 to address the major risk factors of NCDs and tobacco as number one priority8,10.

WHO MPOWER, WHO Framework Convention on Tobacco Control (FCTC) and Tobacco Cessation

The WHO devised MPOWER as the global WHO strategy in 2007 to realize the guidelines laid under the WHO FCTC. It outlined the measures for the member countries to implement reduction of demand for tobacco. In the acronym MPOWER, ‘M’ stands for Monitoring tobacco use, ‘P’ for Protecting people from tobacco smoke, ‘O’ for Offer to quit, ‘W’ for Warning about dangers of tobacco, ‘E’ for Enforcing tobacco advertisement, promotion and sponsorship bans and ‘R’ for Raising taxes on tobacco17.

Currently, MPOWER covers 5.3 billion people in the world by its one measure at least10,17,18. Furthermore, 4.4 billion people get covered by at least two MPOWER measures, an improvement of 11 per cent in just two years, from 2018 to 202018. We have chosen to address the ‘O’ component of MPOWER2 because quitting tobacco has ease of obtaining a strategic and procedural concurrence and smoother implementation. The ‘O’ in MPOWER1 has been addressed specifically by the WHO FCTC through Article 14⁺. It advises parties to take suitable but impactful measures in designing and implementing effective programmes that shall encourage stopping tobacco use by providing adequate treatment for tobacco dependence to 39 per cent of men and nine per cent of women worldover17,19,20. Currently, ‘O’ is the third most adopted measure of MPOWER that provides comprehensive coverage to 2.6 billion people in 26 countries (32% of the world population), i.e. their cost is covered for nicotine replacement therapy (NRT) in addition to the free availability of cessation services at primary healthcare facilities along with national quitline and mobile phone text messaging. The coverage is partial for 110 countries (cost-covered for either NRT or cessation service), minimal for another 26 countries (neither NRT nor cessation service has cost-covered) and none in the remaining 32 countries20.

Under Article 14, the key recommendations from the defined guidelines18 for its member countries include:

i.Developing an infrastructure that shall support TCs and treatment of tobacco dependence through national coordination and collaboration along with sustenance of adequate resources.

ii.Both health and non-health systems shall help tobacco users quit by raising their awareness through mass media campaigns and providing population-based and individual approaches that are evidence based; these shall also make provisions for pharmacotherapy.

iii.Generating cessation support through a stepwise approach in the health system that shall (a) identify and prompt the tobacco users including the tobacco-using health workers to quit, and (b) the one that integrates at least a very brief advise.

iv.Monitoring and evaluation of all strategies and programmes, based on local circumstances that shall have defined outcomes and robust data recording system, and exchange information with other members to get benefitted mutually.

v.International cooperation to (a) share and implement their most effective TC and cessation outcome measures received through an international reporting and review mechanism and, in turn, (b) revise guidelines that shall improve the guidance and assistance.

The use of some words in the original text in terms of their meaning appears to specify how these should be adopted and implemented optimally - parties, infrastructure, resources, health system, healthcare professionals (HCPs), population and individual approaches, training, data collection and reporting17.

We concur with Romeo-Stuppy et al21 who extrapolated the issue of human rights with tobacco cessation delivery in reference to the UN commitments under the International Covenant on Economic, Social and Cultural Rights (ICESCR) earlier22 and more recently under the Guiding Principles on Business and Human Rights23. They stated that it is a violation of human right when governments fail to either discourage production, marketing and consumption of tobacco22 or ensuring availability of quality-based TC services, accessible and acceptable as ‘Right to Health’23. There is an urgent need to increase the onus on (i) policy makers (their will to plan, provide adequate resources, implement effectively, resolve challenges as well as barriers and be accountable), (ii) health systems and HCPs (to get empowered to establish, support24 and deliver TCs effectively) and (iii) the Medical/Dental/Nursing Councils to prioritize TCs delivery as CME credits and their respective associations to include TCs in all their activities and deliver it to all tobacco using patients at every clinical encounter. Such measures will also provide opportunity for: (i) the masses (population at large and the communities and individuals specifically) to know the benefits of quitting, (ii) tobacco users to demand prompt treatment for tobacco dependence from the HCPs along with total coverage of the cost by the health insurance agencies, (iii) the HCPs to deliver tobacco dependence treatment at every clinical opportunity to all tobacco-using patients and (iv) the enforcers to ensure that all public- and work-places and public transports comply to the Cigarette and Other Tobacco Products Act (COTPA) norms.

Referring again to the case study of India, the benefits in economic terms can be significant given the costs of counselling a tobacco user and quitter obtained through its National Tobacco Quitline Services (NTQLS) - 22.37 USD (1,843.51 INR) and 69.96 USD (5,765.40 INR), respectively3,25. Considering that all tobacco users above 18 yr will avail this service (266.8 million)26, the costs for counselling and successful quitting of all will be 5.96 billion USD (491.16 billion INR) and 18.66 billion USD (1,537.77 billion INR) respectively3,25,26. Assuming such an eventuality, the country has the potential to save 27.5 billion USD (2,266.27 billion INR) on account of tobacco-related illnesses and deaths27. In this context, it will be worth reviewing the overall status of SDGs in reference to the control of tobacco and its cessation identifying necessary resources, building capacity and capabilities along with sustained engagement of its stakeholders, prompt implementation of the effective enforcement processes for achieving the outcome measures (the revised targets) and improving monitoring, evaluation and reporting to improve constantly in making our world tobacco free.

The recommendations made here echo the Chandigarh declaration made on its concluding day - September 27, 2021 at the Fifth National Conference on Tobacco or Health (NCTOH) held at Chandigarh, India28. It was shared with over 1500 delegates observing that it should be accepted as a National Mission by the Government of India in view of its worthiness as a fundamental right of all Indians ‘to enjoy the health at its best and holistically’ and to meet the goals of SDGs besides several national health programmes including Ayushman Bharat and TB-Free India. To be effective, the declaration also proposed the constitution of a national regulatory authority and a national advisory board that should have specific committees to work on different aspects of TC and with a resolve to bring an endgame for tobacco in the country by the year 2030 - ‘the last decade in the history of tobacco causing harms to its citizens’.

Within the continuum of TC, prioritizing TCs (Article 14 of the WHO FCTC) can become a catalyst14,18,20. The international support provided by the UN to the key recommendations of the WHO FCTC for improving the existing health infrastructure and systems that identifies and treats tobacco users promptly along with its monitoring, evaluation and reporting is critical20. The ‘O’ in MPOWER14 needs a revised understanding as an increasing ‘onus’ upon all the stakeholders - mainly the policy makers, strategists, health systems and the HCPs to deliver tobacco cessation. The sooner it is done, the better it will be since the economic losses currently incurred by any country can be minimized significantly in comparison with the investments made in upscaling the tobacco cessation delivery through the national tobacco quit line services (NTQLS)25,27. The Chandigarh 5^th NCTOH declaration fittingly announced the twenties of this millennium as ‘the last decade’ in which tobacco causes any harm to its citizens28.