The Tobacco Endgame Supported by the Principles of Human Rights and Bioethics

Commentary

During the 56th World Health Assembly in 2003, the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was adopted with the goal of addressing the global tobacco epidemic. The FCTC represents the largest international treaty adopted by the United Nations and the first major public health treaty of the WHO. Parties to the FCTC have made a commitment and a responsibility to the international community to implement and enforce the normative content of tobacco control actions that aim to reduce both the demand and the supply of tobacco [1].

In addition, the FCTC brings other obligations in its 38 articles: to consider the participation of civil society, to protect public policies from tobacco industry interference, to protect the environment and people’s health, to consider legislative actions related to civil and criminal liability, to establish research and surveillance programs, and to facilitate information exchange and international cooperation [2].

Health formally recognized as a Human Right emerged in the Universal Declaration of Human Rights (1948), in its article 25, which highlights the right of all people to a standard of living adequate for the health and well-being of themselves and their families. Therefore, health is indispensable to human life and based on the values of freedom, equality, and dignity. It is noteworthy that health is one of the irrevocable goods, thus receiving the State’s protective guardianship [3].

The tobacco epidemic is considered the leading preventable cause of death in the world, since smoking is responsible for causing at least 50 types of disabling diseases including Chronic Non Communicable Diseases (heart disease, lung disease, and cancer). According to the Commentary WHO, smoking causes the death of at least 6 million people annually. Estimates indicate that if the trends continue, there will be 8 million deaths annually, and 80% of these deaths will occur in low and middle-income countries [4]. Despite the advances in tobacco control, data reveal that in South America, the prevalence rates of smokers range from 1.9% among women in Ecuador to 32.1% among men in Bolivia. The highest prevalence rate is observed among Chilean women smokers (22.7%), followed by Uruguayan women smokers (17%). The second highest value among male smokers was observed in Chile (27.7%) followed by Suriname (27.3%) [5].

The same survey also points out that Brazil is among the 10 countries with the highest total number of smokers. However, the country stands out for the advances made in tobacco control in recent decades, obtaining the largest reduction in the prevalence of smokers in both sexes between 1990 and 2015, registering a reduction in the prevalence of smokers in 56.5% in men and 55.8% in women. It is estimated that in Brazil, 18.7% of the population are smokers [5].

However, just following the recommendations of the FCTC may not bring the results that the world population needs to eradicate the tobacco epidemic in the shortest timeframe recommended by tobacco control experts in order to reduce the number of global deaths and the costs arising from tobacco-related diseases. The experts have developed a strategic plan as a bold way to decrease the prevalence of smoking to acceptable levels, since the number of deaths and the damage caused to the world economy are unsustainable [6].

From this perspective, the concept called Tobacco Endgame was born. The Endgame proposes innovative strategies that can accelerate the decline in smoking prevalence in the shortest possible time. In the same way that the sociologist Herbert de Souza immortalized the phrase: “Those who are hungry are in a hurry”, expressing the urgency of the poorest people regarding hunger, misery and malnutrition, by analogy, smoking for public health is an urgent matter: we are in a hurry for this great evil to have an Endgame for humanity. The WHO Framework Convention on Tobacco Control is an evidence-based tool used to enforce tobacco control measures and has been widely adopted in more than 180 Parties, and recently its goals and guidelines have been included in the sustainable development goals for all countries for the next 15 years [7].

Since the FCTC came into force, an increasing number of Parties have made progress in implementing tobacco control legislation and smoking has declined, especially in high- income countries. However, more than 80% of the world’s 1 billion total smokers live in low- and middle-income countries, and therefore, much progress is needed for most countries to achieve the goal of a 30% reduction in adult tobacco use worldwide by the year 2025 [8].

The implementation of the FCTC has made a positive contribution to tobacco control worldwide and has contributed significantly to the rapid progress of effective measures related to some articles of the treaty. Although there is evidence of recent progress in some countries, most countries have made slow progress in implementing the FCTC [9]. Overall, the FCTC has been increasingly cited by countries as a powerful instrument for tobacco control measures, but it is necessary to defend this treaty against industry interference, particularly in judicial review, either nationally or internationally.

The tobacco industry continues to use strategies that secure its interests and undermine the tobacco control measures advocated by the WHO. The tobacco industry uses its financial influence to hinder the formulation of tobacco control policies and other measures such as advancing the global fight against illicit trade in tobacco products [9]. In many countries, progress on the Framework Convention continues to be hampered by tobacco industry interference, lack of financial or human resource support, and weak enforcement of tobacco control laws and measures [9].

Despite this scenario, some FCTC measures are considered effective to reduce tobacco consumption and the health risks caused by smoking and to promote the encouragement of cessation. Among the articles that stand out in these measures are: Article 6 (Measures related to prices and taxes to reduce the demand for tobacco), Article

8 (Protection from exposure to tobacco smoke), Article 11 (Packaging and labeling of tobacco products), Article 12 (Education, communication, training and awareness of the public), Article 13 (Tobacco advertising, promotion and sponsorship), Article 14 (Demand reduction measures related to tobacco dependence and cessation), Article 16 (Sale to or by minors) [9].

However, there are still gaps in the literature on this topic, for example, there are no research results evaluating the effectiveness of measures implemented to prevent tobacco industry interference (Article 5.3), regulation of the contents of tobacco products (Article 9), support for economically viable alternative activities (Article 17), protection of the environment and human health (Article 18), accountability (Article 19), and scientific, technical and legal cooperation and provision of specialized assistance (Article 22). Additionally, there is limited research investigating the impact of the FCTC on gender-related issues and among groups of people in vulnerable situations [9].

The relationship of human rights and tobacco control is very close, as non-smokers have the right guaranteed in Article 8 of the FCTC to breathe smoke-free air and to be protected from various diseases caused by secondhand smoke. In addition, tobacco users have the right to be informed about the products they consume, including the health risks and information about cessation. Once addiction sets in, smokers do not freely decide whether to smoke or not. Tobacco use is a violation of human and bioethics rights and represents serious restrictions in the lives of people with chronic respiratory diseases who need to avoid places where smoking is still a permitted or acceptable practice [10].

The tobacco industry uses human rights arguments to defend its abusive and deadly practices by arguing that people have the right to smoke wherever they want and that it is the right of companies to advertise their products freely, since they are legal products. However, these arguments are fallacious for several reasons: first, freedom of speech should not be confused with commercial freedom or free and unrestricted advertising, since advertising of dangerous legal products should be banned from communication channels [10].

Secondly, when a person becomes dependent on the nicotine contained in tobacco products and their derivatives, the smoker has no free choice to decide whether or not to smoke, the brain receptors drive the smoker to seek more and more of the drug to have the feeling of satiety, so the real violation of human rights is to promote a product that causes addiction and deaths [10].And finally, the freedom to smoke is a false freedom, because there is evidence that secondhand smoke can cause disabling diseases, including cancer, in people who do not smoke but are frequently exposed to cigarette smoke. Thus, no one has the right to release thousands of toxins into the air that other people breathe [10].

The Endgame of the tobacco epidemic is a concept that proposes a smoke-free future where tobacco products would be eliminated from the market or their use and availability would be restricted. This proposal is aligned not only with the guarantee of human rights to health, but also with bioethical principles, as it calls for international cooperation efforts as a means to realize health rights. To achieve this goal, countries willing to join the Endgame should accelerate tobacco control actions either through bolder strategies, more drastic methods, or a more forceful policy approach [11].

It was observed that in the literature, the definition of End Game strategies for the Tobacco epidemic brings together those aimed at changing or permanently eliminating the structural dynamics of the tobacco market, and suggest the implementation of economic and social policies that hinder the tobacco industry’s strategies to remain in the market. These strategies can be categorized into innovative actions focused on the product, the user, the market/supply, and the institutional structure (governments and/or tobacco industry [11].

Some countries have official documents on the End Game strategy for the tobacco epidemic such as Ireland which proposes a smoking prevalence target below 5% by 2025. Scotland, on the other hand, proposes to reach the same smoking prevalence target (5%) in a longer timeframe, by 2034, New Zealand proposes to reach minimum smoking prevalence levels (or even 5%) by 2025. Finland has a bold goal of zero smoking prevalence by 2040, or sooner. Canada has proposed to achieve a goal of less than 5% smoking prevalence by 2035 [11].

In general, experts say that most countries that have implemented the FCTC actions are ready to face the challenge of designing a strategic Endgame plan for the tobacco epidemic. However, it is essential that countries set clear goals, estimate the direct (per capita) costs of achieving the goals, and set a deadline for achieving them. These new actions can be aligned with the guidelines and goals of the FCTC/WHO or innovate proposals to the international treaty based on the human rights in health, the principles of bioethics and the objectives of sustainable development [11].