|Year : 2011 | Volume
| Issue : 3 | Page : 184-191
WHO framework convention on tobacco control and its implementation in South-East Asia region
Dhirendra N Sinha, Jai P Narain, Nyo Nyo Kyaing, Sonam Rinchen
Tobacco Free Initiative, World Health Organization, Regional Office for South-East Asia, New Delhi, India
|Date of Web Publication||16-Nov-2011|
Dhirendra N Sinha
Regional Advisor, Surveillance (Tobacco Control), World Health Organization, Regional Office for South-East Asia, IP Estate, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The birth of the WHO Framework Convention on Tobacco Control (WHO FCTC) took place in response to the global tobacco epidemic and it became the most important global tobacco control instrument. Duly recognizing tobacco use as an important public health problem and in the wake of rising prevalence of and mortality related to tobacco use, almost all Member States of the South-East Asia Region signed and ratified the WHO FCTC. Following the ratification, Member countries have enacted comprehensive national tobacco control laws and regulations. Most countries have covered some important provisions, such as tax and price measures, smoke-free places, health warnings, a ban on tobacco advertising and promotion, and a ban on tobacco sales to minors. In spite of innumerable constraints and challenges, particularly human, infrastructural and financial resources, Member countries have been doing their best to enforce those legislations and regulations as effectively as possible. In order to educate the general public on the harmful effects of tobacco, mass health campaigns have been organized which are being continued and sustained. However, some of the important areas that need attention in due course of time are tax raises, illicit trade, tobacco industry interference and alternate cropping systems. All Member States in the Region are striving harder to achieving the goals and provisions of the Framework Convention through actively engaging all relevant sectors and addressing the tobacco issue holistically, and thus protecting the present and future generations from the devastating health, social, economic and environmental consequences of tobacco consumption and exposure to tobacco smoke.
Keywords: WHO FCTC, Articles, Implementation, Tobacco control
|How to cite this article:|
Sinha DN, Narain JP, Kyaing NN, Rinchen S. WHO framework convention on tobacco control and its implementation in South-East Asia region. Indian J Public Health 2011;55:184-91
|How to cite this URL:|
Sinha DN, Narain JP, Kyaing NN, Rinchen S. WHO framework convention on tobacco control and its implementation in South-East Asia region. Indian J Public Health [serial online] 2011 [cited 2019 Dec 10];55:184-91. Available from: http://www.ijph.in/text.asp?2011/55/3/184/89949
| Introduction|| |
The WHO Framework Convention on Tobacco Control (WHO FCTC) was developed in response to the globalization of the tobacco epidemic. It is the first global treaty negotiated under the auspices of the World Health Organization and entered into force in February 2005. The WHO Framework Convention is an evidence-based treaty that reaffirms the right of all people to the highest standard of health. The Framework Convention provides the principles and context for policy development, planning of interventions and mobilization of political and financial resources for tobacco control. The Framework Convention is the supreme global tobacco control instrument, which contains legally binding obligations for its Parties. To address the complex set of determinants for tobacco control, this Framework Convention asserts the importance of demand reduction strategies as well as supply issues and includes the following important Articles, as below: 
- Article 6: Price and tax measures to reduce the demand for tobacco
- Article 8: Protection from exposure to tobacco smoke
- Article 11: Packaging and labelling of tobacco products
- Article 12: Education, communication, training and public awareness
- Article 13: Tobacco advertising, promotion and sponsorship
- Article 16: Sales to and by minors
- Article 20: Research, surveillance and exchange of information
Tobacco use kills about 1.3 million people each year in the South-East Asia Region. The Region is home to over 240 million smokers and a large number of smokeless tobacco users. There is a rising trend of tobacco use among young girls and women. In addition, smokeless tobacco use is prevalent among women, especially in Bangladesh, India and Nepal. India and Indonesia are among the top 10 tobacco-producing and consuming countries in the world.  Hence, tobacco use is an important public health problem in the Region. In the wake of an increasing trend of tobacco use in the Region and in response to the tobacco industry's aggressive attempts at expanding its markets in the developing world, ten Member countries of South-East Asia ratified the Framework Convention and earnestly put in place appropriate tobacco control legislation and regulations. Currently, Member countries are at various stages of implementing the provisions of the Framework Convention. While the countries are making concerted efforts in achieving the goals of the Convention, they are also increasingly facing many constraints and challenges in implementing the tobacco control measures.
| History of the WHO FCTC and its development in SEA Region|| |
The initial conceptualization of an international legal approach to tobacco control dates back to 1993-1994 when the late Dr. Ruth Roemer (staff of WHO) came up with the idea of using international treaty law as a public health approach to tackling tobacco use. A year later, during the 49 th session of World Health Assembly the concept of an international strategy for tobacco control was introduced and the resolution (WHA49.17) was adopted directing the WHO Director-General to initiate preparations of a framework convention on tobacco control. But it was not until 1998 that the transition from the concept of a framework convention to reality took place. The newly elected Director-General accorded high priority to tobacco control and created the WHO Tobacco Free Initiative (TFI). Between 1999 and 2002, through the intergovernmental negotiating body and Technical Working Group, the negotiations on the WHO FCTC took place urging all the Member States to support the treaty. Finally in May 2003, the Fifty-sixth session of the World Health Assembly unanimously adopted the WHO Framework Convention on Tobacco Control, making it the first global treaty negotiated under the auspices of the World Health Organization. The Framework Convention entered in force in February 2005.  It has since become one of the most widely embraced treaties in UN history. As of July 2011, there are 174 Parties to the Framework Convention.
The South-East Asia Region actively participated in the development of guidelines and protocols on different provisions of the Convention and hosted the meeting of the Conference of Parties (COP). Ten Member countries have ratified the Framework Convention and are Parties to the Convention. The ratification of the WHO Framework Convention on Tobacco Control offered Member States an unparalleled opportunity to pass or amend their domestic legislation, and develop and enforce effective policies and programmes. Member countries of the Region are at various stages of implementation and the challenge remains for all to move towards complete implementation of the treaty.
| Obligations and implementation of Framework Convention|| |
Article 5 of the Framework Convention stipulates that each party shall develop, implement, update and review comprehensive multi-sectoral national tobacco control strategies, plans and programmes in accordance with this convention and the protocols to which it is a party.
In an effort to respond to the provisions of the Framework Convention, Member States have developed comprehensive tobacco control policies, plans and strategies and are dynamically engaged in implementing them for the best outcomes. Nine Member States (Bangladesh, Bhutan, DPR Korea, India, Maldives, Myanmar, Nepal, Sri Lanka and Thailand) ,,,,,,,, in the Region have comprehensive national tobacco control laws. Indonesia has issued a Presidential Decree on Making Cigarettes Less Harmful to Health (2003) and the Law of Republic of Indonesia Number 36 enacted in 2009 has some provisions for tobacco control.  The legislation of most countries have provisions on smoke-free places, a ban on tobacco advertising, promotion and sponsorship, and a ban on tobacco sales to minors. In conformity with the Regional Committee Resolution (SEA/RC61/R4), all Member countries in the Region have adopted the MPOWER measures as an operational tool to implement tobacco control effectively.
The Framework Convention had a significant effect on redirecting tobacco control policies at both the regional and national levels. The ratification of the Framework Convention has provided the anti-tobacco Coalitions in the Member countries with the impetus to combat tobacco. In order to achieve effective implementation of the Framework Convention, national tobacco control laws have been developed and passed in nine Member countries. Timor-Leste is in the process of drafting national legislation on tobacco control.
Effective implementation of the Framework Convention can only be achieved through active engagement of all relevant sectors of the government, nongovernmental organizations and civil society, as well as involving new partners to take action within their political, occupational, social and cultural networks and spheres of influence. The Member countries need to work consistently for complete implementation of the treaty so as to reap the health, social and economic benefits of tobacco control.
In view of facilitating the implementation process for the Convention, WHO-SEARO supported Member countries in many areas of tobacco control measures.
- Provided technical and financial support in drafting and developing legislation and regulations in Bhutan, Bangladesh, Nepal, Myanmar and Maldives.
- Supported capacity building training for Finance department personnel from Bangladesh, India, Indonesia, and Thailand.
- Supported health cost and poverty studies in Bangladesh, Sri Lanka and Myanmar.
- Developed IEC materials for the countries
- Supported observation of World No Tobacco Day in all Member countries.
- Fostered regional goodwill and cooperation through advocating tobacco control in regional platforms such as ASEAN and SAARC.
| Progress for specific provisions of the WHO Framework Convention|| |
Price and tax measures to reduce the demand for tobacco (Article 6)
Article 6 states that the Parties recognize that price and tax measures are an effective and important means of reducing tobacco consumption by various segments of the population, in particular young persons.
Cigarette tax in the region varies from 29% in Nepal to 73% in Sri Lanka in 2010.  Although countries have increased taxes in every fiscal year, over the last decade cigarettes have become more affordable in many countries in the Region as inflation rates have not been taken into account while raising taxes.  Also, the trend of GDP per capita required buying cigarettes declined over the years, indicating an increase in actual affordability for cigarettes.  [Figure 1].
|Figure 1: Increasing affordability of cigarettes in select Member countries the Region|
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Taxation on other tobacco products is far less than cigarettes and hence easily affordable to the poor section of the people. For instance in India, the revenue that is generated from bidis is insignificant compared with cigarettes indicating a wide disparity of tax application between these two smoking items even though ten bidis are smoked for every cigarette consumed. The total percentage of revenue contribution from bidis in 2006-2007 was only 5.7% as opposed to 94.3% for cigarettes. 
To protect the poor from the devastating health and economic impacts of tobacco use, it is important to ensure that tobacco tax on all products are harmonized and meet the standards of the World Bank. Thailand, India and Nepal set good examples on this in the Region because part of their tobacco taxation revenue is earmarked for health issues. 
Protection from exposure to tobacco smoke (Article 8)
In keeping with Article 8 of the Framework Convention, Member countries have taken legislative, executive and administrative measures to protect people from exposure to tobacco smoke in indoor places, public facilities and other indoor public places, and on public transport. All Member countries have smoke-free policies in place for health-care facilities, which is closely followed by educational facilities (10 countries) and universities (9 countries). Seven countries reported having a complete protection against second-hand smoke in government buildings, while six countries have policies in place for indoor offices. There are nine countries which reported that they have national laws mandating fines for smoking and levying fines on the smokers.  However, the protection from SHS exposure in restaurants, pubs and bars seems very low in most of the countries [Table 1]. Countries are making efforts to implement the policy through public education and various other strategies.
Packaging and labelling of tobacco products (Article 11)
Article 11 of the Convention mandates each party to adopt and implement effective measures ensuring that tobacco product packaging and labelling do not promote a tobacco product. In response to this Article, three countries in the Region have implemented specific health warning labels while a few others are in the process of developing strategies and implementing them. Studies have shown that health warning labels have a positive impact in some countries. India has implemented graphic health warnings on all kinds of manufactured tobacco products. Thailand implemented ten rotating graphic warnings covering 55% of the front and back surface area of cigarette packets, five rotating graphic warnings on cigar packets covering 50% and two graphic warnings on roll-your-own cigarettes. Bangladesh has provisions providing six rotating textual-specific health warnings on smoking tobacco products but has implemented the same only on the packets of manufactured cigarettes.  The recently passed tobacco control bill of Nepal mandates all tobacco companies to cover 75% of cigarette and other tobacco product packaging space with pictorial health warnings.  In Bhutan, a person shall not import tobacco and tobacco products if they do not show the country of origin and health warning on the packages. 
Education, communication, training and public awareness (Article 12)
Complying with the article 12 of the Convention, many Member countries in the Region are making efforts in developing IEC materials on tobacco control issues and disseminating them to wider target audience through use of appropriate media. Bhutan, India, Myanmar, Nepal Sri Lanka and Thailand have conducted national mass media campaigns in 2009-10 to inform and educate the public about the harms of tobacco use and support tobacco control policies. 
Tobacco advertising, promotion and sponsorship (Article 13)
Article 13 is well addressed through placing appropriate policies in countries of the Region. All Member countries (except Indonesia and Timor-Leste) have a policy banning various forms of direct tobacco advertising and promotion on national television, radio, billboards, outdoor advertising and sponsored events. Some countries have even banned tobacco advertising on international TV/radio and in international magazines/newspapers. The indirect bans such as on free distribution, promotional discounts and the appearance of tobacco brands in TV/films are in place in most of the countries [Table 2]. Indonesia has limited provisions, but it restricts free distribution of tobacco products. However implementation of policies remains a big challenge in the Region.  Survey findings show that a large proportion of the population, particularly young boys and girls face high exposure to tobacco advertising and promotion campaigns. The tobacco industry uses tactical and innovative ways to reach its tobacco products to all sections of its targets, including youth and women.
Tobacco cessation (Article 14)
Article 14 of the Convention affirms that each party should develop and disseminate comprehensive guidelines and take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. To this effect, many countries have initiated the establishment of cessation services with support of WHO. Although there is enough indication that most of the users are willing to quit their tobacco habit, currently Member States are still endeavouring to have adequate facilities and training provisions on cessation services. India has 20 tobacco cessation centres and few community cessation clinics. Thailand has a good network for community health cessation. India and Thailand have developed national tobacco cessation guidelines and recently launched national quitlines and telephonic helplines. India is also trying to establish tobacco cessation at the district level. In order to support Member countries, WHO-SEARO developed and distributed the following technical documents: 
- Helping People Quit Tobacco: A Manual for Doctors and Dentists.
- Tobacco Cessation: A Manual for Nurses, Health Workers and Other Health Professionals.
- Manual on Tobacco Control in Schools.
- Community Cessation Manual.
WHO-SEARO also supported community cessation programmes in six Member countries. SEARO provided training at the regional level on tobacco cessation and has also supported national tobacco cessation training in many countries of the region. The tobacco control manual for schools has been translated into different languages for use by different Member States. Training of teachers has also been supported in some Member States.
Sales to and by minors (Article 16)
Implementation of the provisions of Article 16, which mandate the governments to adopt and implement measures to prohibit the sales of tobacco to minors, is poor in most of the countries of the Region. Survey findings in the countries show that many young boys and girls can still buy cigarettes from a store in many countries of the Region. The percentage of boys and girls who could get cigarettes from a store ranges from a high of 75% in Sri Lanka to 24% in Myanmar. Almost every current smoker among the youth in Bangladesh (98%) can get cigarettes without being refused from sellers on account of their age [Figure 2]. A significant percentage of ever-smokers started smoking at much younger age. For instance, about two to four out of every ten ever-smokers were initiated to smoking before the age of 10 years in the Region. Such information calls for an urgent need to incorporate provisions regulating the sale to minors in the laws of all Member countries as well as ensure effective implementation of enforcement policies.
|Figure 2: Access and availability of cigarettes to students aged 13– 15 years in select Member countries of the Region|
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Monitoring tobacco use (Articles 20)
The Region has conducted the Global Youth Tobacco Survey (GYTS) in ten Member countries. It supported the collection of valuable information on the prevalence of tobacco use, knowledge and attitudes towards cigarette smoking, role of the media and advertising, access to cigarettes, exposure to secondhand smoke (SHS) and information on cessation of cigarette smoking. Bhutan, India, Indonesia, Maldives and Timor-Leste have conducted two rounds of national GYTS. Myanmar, Sri Lanka and Thailand have conducted three rounds of national GYTS. In the Region, nine Member countries have conducted Global School Personnel Survey (GSPS) on a national sample. India, Indonesia, Thailand and Timor-Leste have conducted two rounds of GSPS. The Global Health Professions Students Survey (GHPSS) was conducted in seven Member countries of the Region. GHPSS for medical and dental students have been conducted in six Member countries. GHPSS for pharmacy students has been conducted in five Member countries, and for nursing students in two countries. The Global Adult Tobacco Survey (GATS) has been conducted in Bangladesh, India and Thailand. A repeat GATS is under process in Thailand.
Article 21 of the Convention states that that each party shall submit to the Conference of the Parties periodic reports through the secretariat at the regular interval of two years. Almost all parties in this Region have complied with this provision through submission of their first report. Bangladesh, India and Thailand from the Region submitted their five-yearly reports.
Bangladesh and Bhutan conducted a needs assessment on tobacco control initiatives. A Joint mission comprising members from WHO FCTC Secretariat, WHO-SEARO and MOH of Bangladesh and Bhutan conducted the assessment of needs for implementation of WHO FCTC in 2009 and 2011 respectively. The mission identified and highlighted the need to enhance public education on the Tobacco Control Act and to train law enforcement officials. The full report of the joint needs assessment is under publication.
| Challenges and way forward|| |
Successful implementation of tobacco control measures underscores the need to address the social and cultural factors that determine the use of tobacco in South-East Asia. Misconceptions among people about tobacco use, created by the social and cultural beliefs, come handy to the tobacco industry and use this as the basis for developing marketing strategies. To counter this, community-based programmes need strengthening with the involvement of community stakeholders such as religious persons, teachers, youth, civil society, etc and media to dispel their misbelief by educating them on many harmful manifestations of tobacco use.
Based on existing scientific evidence on harmful health effects of tobacco products including smokeless tobacco, there should be comprehensive advocacy programmes at all levels supporting a complete ban on the manufacture, marketing and sale of tobacco products in the Region. A set of recommendations ensued from the National Consultation on Smokeless Tobacco in India is one of the best examples of designing some interim measures to reduce the use of smokeless tobacco products until their complete ban is endorsed and implemented. For instance, Prevention of Food Adulteration Act (1954) and Food Safety Act (2006) could be used to prohibit the sale of smokeless tobacco products by considering them as food items containing substances which are injurious to health. So, other countries may also take such ingenious approaches by using the non-tobacco related acts and regulations to control the sale of tobacco products.
Even though the Member countries have legislation and regulations on tobacco control in place, enforcing them effectively is still a big problem. Since enforcing and monitoring the implementation of tobacco control measures involves various stakeholders, building partnership among them and bringing about coordinated effort and synergistic force remains a weaker link when it comes to enforcement. Thus, WHO and all stakeholders should make concerted efforts to collaborate in this area of enhancing the capacities of law enforcers and educating public for compliance to the legislation.
Inter-sectoral coordination and concerted efforts are required by various stakeholder ministries e.g. Health, Finance, Agriculture, Information and Broadcasting, Rural Development, etc for developing strategies and policies to look at measures related to reduce the demand as well as the supply of tobacco in the country. Some of the areas which need attention are tax raise for tobacco products, and illicit trade of tobacco products, awareness generation on harmful effects of tobacco on health, banning advertisements, providing alternate crops and livelihoods to tobacco farmers/ growers and workers. Tobacco farmers and growers need to be informed and assisted with economically viable alternative crops with an established mechanism and assurance for marketing of such alternative crops. Tobacco workers must be provided with information on alternative livelihood options and assisted to shift over to economically viable and safer livelihood options.
Existing policies which are not directly related to tobacco control but having considerable impact on the tobacco control may be used as one of the strategies. Making retail sellers the point of taxation by licensing sale of tobacco products, imposing license fee and other municipal taxes and mandating higher rates of premium for health insurance are some of innovative methods to reduce demand for tobacco products. Also, undertaking research on productivity and wage loss or economic burden of tobacco, alternative livelihood, crop substitution, illicit trade, etc will be a worthwhile attempt at creating persuasive evidence and bring about effective policy changes.
One of the main obstacles in tobacco control is interference by the tobacco industry in legislative and policy-making processes through lobbying and partnering with organizations inside and outside of government, as well as asserting and maintaining direct and indirect influence on policy-makers, political leaders and researchers. The Bidi industry has tried to protect themselves as poor cottage industries and as a source of employment for the poor, which indeed is a pretext to promote the industry products. Governments should offset such arguments with concrete evidence proving that tobacco brings much more harm to the society than any good and convince the general public of the negative impact of tobacco consumption with compelling scientific evidence.
Although almost all countries are Parties to the Convention, there are still huge gaps to meet the goals of the WHO FCTC via effective implementation of the provisions of the Convention. Major challenge in the implementation of tobacco control measures include:
- Weakness in tobacco control policy
- Weak enforcement of tobacco control legislation
- Weak public awareness campaigns on the adoption of legislations
- Limited human and financial resources dedicated to tobacco control
- Tobacco industry influence on policy makers, farmers and other stakeholders of tobacco control
- Social and cultural acceptance of tobacco use as a norm
Priority areas that need to be strengthened in the Region regarding the tobacco control include:
- Strengthening tobacco control policy including adequate taxation policy on all forms of tobacco products
- Measures to reduce prevalence of smokeless tobacco
- Cessation of tobacco use, both community based and clinic based
- Effective implementation of tobacco control legislation /WHO FCTC
- Public health education including Product regulation and disclosure
- Regional cooperation for control of illicit trade especially through border trade and control of cross border advertising
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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