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11.1: NCDs/Chronic diseases

NCD =

1

Exam study guide topics (1)

Know the top 5 chronic diseases and that many of them have shared risk factors

Know the 6 risk factors that contribute the most to chronic disease

Know the most “cost-effective” interventions (aka “best buys”) per WHO guidance (see the pdf that we will talk about during lecture) for three of the specific risk factors for NCDs: 1) harmful use of alcohol, 2) physical inactivity, and 3) tobacco use

Understand the difference between primary, secondary, and tertiary prevention. If given an example of an intervention (e.g., colonoscopies, healthy eating education, stroke rehabilitation services), determine if it is an example of primary, secondary or tertiary prevention.

2

Learning objectives (2)

Why do some people say that cervical cancer and liver cancer blur the line between infectious disease and chronic disease? Be able to explain.

From a list of health interventions, be able to identify which are focused on structural determinants of health and which are focused on individual behaviors

Exam study guide topics (2)

What do we mean by chronic diseases?

Often called NCDs (non-communicable diseases)

The big ones:

1. heart disease & stroke

2. chronic respiratory disease

3. diabetes

4. cancer

5. mental health

Also : blindness, arthritis, musculoskeletal, neurologic disorders and more

4

What do these chronic diseases have in common?

Some have shared risk factors

Often are long-lasting and take a long time to fully develop

Often these diseases co-exist

5

Shared risk factors for NCDs

Tobacco use and exposure to secondhand smoke

High blood pressure

Obesity (high body mass index)

Physical inactivity

Excessive alcohol use

Poor diets (low in fruits and vegetables; high in sodium and saturated fats)

Source: CDC

6

How would these chronic diseases impact the DALY?

In general, NCDs would have high YLL because of so many people dying young from NCDs

In general, NCDs have high YLL because so many people are affected and die from NCDs

In general, NCDs would have a significant number of years of disability due to the long-lasting nature of the diseases (YLD part of the calculation)

A and C

B and C

7

What can excessive alcohol use cause?

Impacts of short-term alcohol use: injuries, violence, miscarriage, risky sex, alcohol poisoning

What about long-term use?

High blood pressure, heart disease, stroke, liver disease, and digestive problems.6,16

Cancer of the breast, mouth, throat, esophagus, liver, and colon.6,17

Learning and memory problems, including dementia and poor school performance.6,18

Mental health problems, including depression and anxiety.6,19

Social problems, including lost productivity, family problems, and unemployment.6,20,21

Alcohol dependence, or alcoholism.5

CDC Fact sheet: Alcohol use and your health

8

3 types of prevention

Primary Prevention—intervening before health effects occur

Secondary Prevention—catching diseases in the earliest stages, before the onset of signs and symptoms

Tertiary Prevention—managing disease post diagnosis to slow or stop disease progression

9

Which type of prevention would an initiative to promote healthier eating be?

Primary prevention because it aims to change the risk factors before disease develops

Primary prevention because the intervention is considered the most important step in addressing chronic illness

Secondary prevention because the intervention utilizes screenings to catch people in the early phases of disease

Secondary prevention because the intervention is considered the second most important step in addressing chronic illness

10

Your ideas: Effective Public Health initiatives targeting 3 risk factors

Harmful use of alcohol

Physical inactivity

Unhealthy diet

11

The WHO’s “Best Buys” for chronic diseases

Document is one of the assigned readigns in this week’s Canvas: or available here http
://www.who.int/ncds/management/WHO_Appendix_BestBuys_LS.pdf

CEA = Cost Effectiveness Analysis

LMIC = Low and Middle Income Countries

12

WHO position on cost-effectiveness as a tool for decision making about public health policy

“Cost-effectiveness analysis is a useful tool but it has limitations and should not be used as the sole basis for decision-making. When selecting interventions for the prevention and control of NCDs, consideration should be given to effectiveness, cost-effectiveness, affordability, implementation capacity, feasibility, according to national circumstances, and impact on health equity of interventions, and to the need to implement a combination of population-wide policy interventions and individual interventions.”

13

Understanding WHO “Best Buys” for NCDs

14

Effective Public Health initiatives targeting 3 risk factors
http://www.who.int/ncds/management/WHO_Appendix_BestBuys_LS.pdf

Which PH measures would be effective?

Look through the BestBuys pdf and pick read the most cost-effective intervention for each of these:

Harmful use of alcohol (p. 7)

Physical inactivity (p. 9)

Tobacco use (p. 6)

WHO, 2017, ‘BEST BUYS’ AND OTHER RECOMMENDED INTERVENTIONS FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES

15

WHO NCD Targets

Governments have endorsed nine global voluntary targets with the overarching aim to reduce premature death from the four major NCDs by 25% by 2025.

Cardiovascular disease

Cancer

Diabetes

Chronic Respiratory diseases

16

17

Secondary prevention of chronic illness

Early diagnosis and treatment of:

High blood pressure

Overweight/obese

High blood sugar levels

Credit: Goldie, S., Global Health Clip-Chronic Disease 1.

18

What about diabetes?

Type I diabetes:

Pancreas doesn’t produce enough insulin

Most often develops in childhood, thought to be an auto-immune disease.

Type II diabetes:

Cells lose sensitivity to insulin

This is an NCD, connected to individual behaviors.

Insulin is important because it keeps blood glucose levels stable in the body. If glucose builds up in the blood, rather than entering cells or being store, it can wreak havoc. Complications of diabetes include Complications of diabetes include kidney disease, nerve damage, heart problems, eye problems, and stomach problems.

19

Type II diabetes risk factors:

You are more likely to develop type 2 diabetes if you

are overweight or obese

are age 45 or older

have a family history of diabetes

are African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander

have high blood pressure

have a low level of HDL (“good”) cholesterol, or a high level of triglycerides

have a history of gestational diabetes or gave birth to a baby weighing 9 pounds or more

are not physically active

have a history of heart disease or stroke

have depression 

have polycystic ovary syndrome , also called PCOS

have acanthosis
nigricans—dark, thick, and velvety skin around your neck or armpits

Source: National Institute of Diabetes and Digestive and Kidney Diseases

20

Global Cancer Facts

Cancer is the second leading cause of death globally.

Tobacco use is responsible for approximately 22% of global cancer deaths.

Cancer causing infections, such as hepatitis and human papilloma virus (HPV), are responsible for up to 25% of cancer cases in low- and middle-income countries.

Late-stage presentation and inaccessible diagnosis and treatment are common in low-income countries.

Source: http://www.who.int/mediacentre/factsheets/fs297/en/

21

Global top 10 cancers

Cancer is a leading cause of death worldwide, accounting for an estimated 9.6 million deaths in 2018. The most common cancers are:

Lung (2.09 million cases)

Breast (2.09 million cases)

Colorectal (1.80 million cases)

Prostate (1.28 million cases)

Skin cancer (non-melanoma) (1.04 million cases)

Stomach (1.03 million cases)

Source: WHO

Source: WHO

22

Risk factors for cancer

According to the WHO, around one third of deaths from cancer are due to:

high body mass index

low fruit and vegetable intake

lack of physical activity

tobacco use

alcohol use

23

Are there any vaccines that prevent cancer?

Cervical cancer:

HPV vaccine

Have you had the HPV vaccine series?

Liver cancer:

Hepatitis B vaccine

24

Cancer prevention: secondary interventions

Screening for Breast, Cervical, Colorectal (Colon), and Lung Cancers

25

CDC works to prevent chronic disease and associated risk factors in 4 ways:

Epidemiology and surveillance refers to systems that are used to track chronic diseases and their risk factors.

Environmental approaches refers to changes in policies and physical surroundings to make the healthy choice the easy choice.

Health care system interventions refers to improvements in care that allow doctors to diagnose chronic diseases earlier and to manage them better.

Community programs linked to clinical services refers to those that help patients prevent and manage their chronic diseases, with guidance from their doctor.

26

Behavioral Interventions versus Structural Interventions

Should we think about a more “BioSocial” approach to NCDs?

27

“What we describe as a structural approach to NCDs focuses on enduring social arrangements that determine the pattern and distribution of NCDs and their risk factors in a society. Even if we assume that individuals have the ability to make rational choice with respect to healthy behavior/lifestyle, such a choice occurs within certain boundaries set by society, government, and organizations [25]. We suggest that a structural approach conceives of the NCD epidemic as the byproduct of changes to domestic and international systems that have dramatically changed modes of living and created environments that encourage the adoption of harmful patterns of behavior.”

https
://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035457/pdf/12992_2018_Article_380.pdf

28

Structural versus individual interventions?

Encouraging someone to eat a healthier diet, versus:

Incentives for supermarkets to locate in lower income neighborhoods

Taxes on sugary beverages

Subsidies for fruits and vegetables rather than for corn and soybeans

Expanding SNAP and WIC benefits

Enacting laws that require a living wage (raising the minimum wage)

Case study of Film: El Susto! (1 hour, 15 min)

We have an amazing opportunity to be among the first people to view the brand new El Susto! documentary. The producer has given our class advane permission to show the film, and eventually it will make it out to high profile film festivals and/or Netflix.

The case study requires you to discuss the film, and there are also several exam study topics related to it. Be sure to check those out before you start watching. Enjoy!


https://vimeo.com/553346634/59943c8eca (Links to an external site.)

 

Here is the film’s promotional site if you’d like to learn more: 
https://elsustomovie.com/ (Links to an external site.)

Assignment Overview

After reading the assigned text, compose a 500 word reflection and submit it to the Canvas discussion board.

Content and Grading

In your reflections, address the following 3 questions.

1. What are the author’s main messages/arguments? What is the main takeaway of this case study? What is the essential background information that we need to understand it? (2.5 points)

2. How does the case study relate to concepts from the course (including lectures, readings and videos)? Connect themes in the case study to at least 2 concepts from the course.  Put these concepts in bold so that we can easily find them when grading, and be sure to explain or elaborate on HOW the case study illustrates, complicates or is connected to that topic. (4 points)

3. Share your personal reaction or stance on the issues developed in the case study. Has it changed your opinion on the topic? Does it relate to your own personal experiences? Does it connect to things you have studied in other courses, or articles you’ve been reading in the news lately? (2.5 points)

4. Proper citations (1 point)

Citations

You must include proper academic citation in your case study reflections. This is a good habit to get into generally. Visit this page for the general course citation guidelines.

· When referring to required course material, use a shortened version of the APA’s author-date, in-text parenthetical citation system, e.g. (Marmot 2010). You can abbreviate our course textbooks to RGH and PIH, or use the case study author’s last name. Be sure to spell the author’s name correctly! Lectures can be cited by the number, e.g. (Ryan lecture 4.2). Videos can be cited by the primary speaker or a shortened version of the title, e.g. (Bad Sugar) or (Rosling).

· When referring to outside articles or sources, use the APA’s author-date, in-text parenthetical citation system, e.g., (Washington Post 2021) and include a hyperlink or full citation to your original source at the end of your submission. Connecting the case studies to outside sources is always welcome, but be sure you are also

· You do not need to write a full bibliography for case study reflections.

relate to concepts from the course (including lectures, readings and videos)? Connect themes in the case study to at least 2 concepts from the course.  Put these concepts in bold 


Required readings and ppt


·
Tobacco Industry Interference: A Global Brief

  Download Tobacco Industry Interference: A Global Brief. 2012. World Health Organization.

· Skim pp. 1-7, read pp. 8-17 carefully.

· “
‘Best Buys’ and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases

  Download ‘Best Buys’ and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases.” 2017. World Health Organization.

· Skim the introductory information, and read pp. 6-9 carefully.

‘ BEST BUYS’ AND OTHER RECOMMENDED INTERVENTIONS
FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES

UPDATED (2017) APPENDIX 3 OF THE GLOBAL ACTION PLAN
FOR THE PREVENTION AND CONTROL OF NONCOMMUNICABLE DISEASES 2013-2020

2

WHAT IS IN THIS DOCUMENT?

This document provides policymakers with
a list of ‘best buys’ and other recommended
interventions to address noncommunicable
diseases (NCDs) based on an update of Appendix
3 of the Global Action Plan for the Prevention and
Control of NCDs 2013–2020. A list of options is
presented for each of the four key risk factors for
NCDs (tobacco, harmful use of alcohol, unhealthy
diet and physical inactivity) and for four disease
areas (cardiovascular diseases, diabetes, cancer
and chronic respiratory diseases).

Mortality and morbidity from NCDs constitutes
one of the major challenges for development
in the 21st century. Around 40 million people
die annually as a result of NCDs, including 15
million people who die too young – between the
ages of 30 and 69. The burden continues to rise
disproportionately in low- and lower
middle-income countries while in all countries,
these deaths disproportionally affect the
poorest and most vulnerable. The majority of
premature NCD deaths in this 30–69 age group
are the result of the four main noncommunicable
diseases: cardiovascular diseases, cancer,
diabetes and chronic respiratory diseases.

In May 2013 the World Health Assembly endorsed
WHO’s Global Action Plan for the Prevention and
Control of NCDs 2013–2020. The global action
plan has six objectives whose implementation at
country level will support the attainment of the
nine NCD targets by 2025, as well as facilitate the
realisation of Sustainable Development Goal 3 –
Good Health and Well-being. Part of this plan
comprises a menu of policy options and
cost-effective and recommended interventions
(“Appendix 3”) to assist Member States, as
appropriate for their national context, in
implementing measures towards achieving the
Sustainable Development Goals (SDG) Target 3.4.

‘BEST BUYS’ AND
OTHER RECOMMENDED
INTERVENTIONS

Since the global action plan was endorsed in
2013, Appendix 3 has been updated to take into
consideration the emergence of new evidence
of cost-effectiveness and the issuance of new
WHO recommendations that show evidence of
effective interventions. The updated Appendix
31 (which reflects changes to objectives 3
and 4 only) was endorsed in May 2017 by the
Seventieth World Health Assembly.

Renamed ‘ Best buys ’ and other recommended
interventions, this updated Appendix 3 comprises
a total of 88 interventions, including overarching/
enabling policy actions, the most cost effective
interventions, and other recommended
interventions. These 88 interventions are
presented in tables, with one table showing the
relevant options for each of the four key risk
factors and four NCDs addressed.

1 Officially called “the updated Appendix 3 of the WHO Global NCD Action Plan 2013-2020.
http://apps.who.int/gb/ebwha/pdf_files/ WHA70/A70_R11-en.pdf

3

HOW WERE THESE
INTERVENTIONS SELECTED?

Interventions in Appendix 3 were updated
taking into consideration the emergence of new
evidence of cost-effectiveness or new WHO
recommendations since the adoption of the
Global Action Plan in 2013. The formulation of
some of the interventions was also refined based
on lessons learnt from the use of the first version
of Appendix 3.

A transparent, unified approach for the
identifications was taken after the first
consultation on updating Appendix 3,
2015 1. From the consultation, the following
effectiveness criteria were used for identifying
interventions:

> An intervention must have a
demonstrated and quantifiable effect size,
from at least one published study in a
peer reviewed journal

> An intervention must have a clear link to
one of the global NCD targets

Using the above criteria, additional interventions
were considered. The intervention list for the
updated Appendix 3 comprises interventions
which have been unchanged from the original
version, interventions which have been
re-worded or revised to reflect updates in
WHO policy or scientific evidence and new
interventions.

Interventions were assessed for cost
effectiveness, feasibility, as well as non-financial
considerations. Interventions which were
assessed for cost-effectiveness by the WHO
CHOICE model are listed for each of the risk
factors and disease areas.

As mentioned, the 16 interventions considered
to be the most cost-effective and feasible for
implementation were those with an average

cost-effectiveness ratio of ≤ I$ 100/DALY 2 averted
in low and lower middle-income countries.
Interventions with an average
cost-effectiveness > I$ 100 are listed next and
may be considered as per the country context.
Interventions that are mentioned in WHO’s
guidelines and technical documents where WHO-
CHOICE analysis could not be conducted are also
listed in the tables under ‘WHO-CHOICE analysis
not available’. Care needs to be taken when
interpreting these lists; for example, the absence
of WHO-CHOICE analysis does not necessarily
mean that an intervention is not cost-effective,
affordable or feasible – rather, there were
methodological or capacity reasons for which the
WHO-CHOICE analysis could not be completed
at the current time. For more information on the
methodology please see the technical annex.2

THE IMPORTANCE OF
NON-FINANCIAL CONSIDERATIONS

Cost-effectiveness analysis is a useful tool but
it has limitations and should not be used as the
sole basis for decision-making. When selecting
interventions for the prevention and control
of NCDs, consideration should be given to
effectiveness, cost-effectiveness,
affordability, implementation capacity, feasibility,
according to national circumstances, and impact
on health equity of interventions, and to the need
to implement a combination of population-wide
policy interventions and individual interventions.

Critical non-financial considerations that may
affect the feasibility of certain interventions in
some settings are shown as a footnote to each
relevant intervention.

1 http://w w w.who.int/ncds/governance/appendix3-update-discussion-paper/en/

2 The International dollar is a hypothetical unit of currency that has the same purchasing power parity that the U.S. dollar had in
the United States at a given point in time.

4

HOW COUNTRIES CAN USE
THIS INFORMATION

Countries can select from the list of best buys
and other recommended interventions, based
on their national context. Consideration for
selection of interventions could include (i)
which interventions will bring the highest
return on investment in national responses to
the overall implementation of the 2030 Agenda
for Sustainable Development; (ii) priority
government sectors that need to be engaged
(in particular health, trade, commerce and
finance) and (iii) concrete coordinated sectoral
commitments based on co-benefits for inclusion
in national SDG responses.

The economic analyses in the technical annex,
upon which this list is based, give an assessment
of cost-effectiveness ratios, health impact and
the economic cost of implementation. These
economic results present a set of parameters for
consideration by Member States, but such global
analyses can be accompanied by analyses in the
local context. Other tools, such as the One Health
Tools are available to help individual countries
cost specific interventions in their national
context.

When considering interventions for the
prevention and control of noncommunicable
diseases, emphasis should be given to both
economic and non-economic criteria, as
both will affect the implementation and
impact of interventions. Non-economic
implementation considerations such as health
impact,  acceptability, sustainability, scalability,
equity, ethics, multisectoral actions, training
needs, suitability of existing facilities  and
monitoring are essential elements in preparing
to achieve the targets of the global action plan
and should be considered before the decision to
implement the items shown in these tables.

The WHO Secretariat will explore options to
provide an interactive web-tool, to enable users
to compare and rank the information according
to their own needs. The detailed description of
the WHO-CHOICE1 methods for these analyses,
including the assumptions, strength of evidence
and the individual studies used to inform the
development of models for each intervention,
will be published separately as peer-reviewed
scientific papers, which will be publicly available
through open access.

1 http://www.who.int/choice/cost-effectiveness/en

5

1 The International dollar is a hypothetical unit of currency that has the same purchasing power parity that the
U.S. dollar had in the United States at a given point in time.

GUIDE TO INTERPRETING THE TABLES

> Overarching/enabling policy interventions are shown by the light green marker.

> Out of the 88 interventions, there are a total of 16 ‘ best buys ’ – those considered the most
cost-effective and feasible for implementation. These are interventions where a WHO Choice
analysis found an average cost-effectiveness ratio of ≤100 I$1 per DALY averted in low- and
lower middle-income countries. They are shown by the dark green marker in the table.

> Other effective interventions for which the WHO Choice analysis produced a cost effectiveness
of above this threshold of I$ ≤100 per DALY averted are shown by the jungle green marker.

> Other recommended interventions that have been shown to be effective but for which no
cost-effectiveness analysis was conducted are shown by the warm green marker.

Overarching/enabling policy interventions.

‘Best buys’: Effective interventions with cost effectiveness analysis ≤ I$ 100 per DALY averted in LMICs.

Effective interventions with cost effectiveness analysis >I$ 100 per DALY averted in LMICs.

‘Other recommended interventions from WHO guidance (cost effective analysis not available).

6

Objective 3 :

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Increase excise taxes and prices on tobacco products

• Implement plain/standardized packaging and/or large graphic health warnings on all
tobacco packages1

• Enact and enforce comprehensive bans on tobacco advertising, promotion and sponsorship1

• Eliminate exposure to second-hand tobacco smoke in all indoor workplaces, public
places, public transport1

• Implement effective mass media campaigns that educate the public about the harms of
smoking/tobacco use and second hand smoke1

• Provide cost-covered, effective and population-wide support (including brief advice,
national toll-free quit line services) for tobacco cessation to all those who want to quit2

• Implement measures to minimize illicit trade in tobacco products

• Ban cross-border advertising, including using modern means of communication

• Provide cessation for tobacco cessation to all those who want to quit

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An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

Non financial considerations

1 Requires capacity for implementing and enforcing regulation and legislation

2 Requires sufficient trained providers and a better functioning health system

TOBACCO USE

> FOR THE PARTIES TO THE WHO FRAMEWORK CONVENTION ON TOBACCO CONTROL (WHO FCTC):

• Strengthen the effective implementation of the WHO FCTC and its protocols

• Establish and operationalize national mechanisms for coordination of the WHO FCTC implementation as
part of national strategy with specific mandate, responsibilities and resources

> FOR THE MEMBER STATES THAT ARE NOT PARTIES TO THE WHO FCTC:

• Consider implementing the measures set out in the WHO FCTC and its protocols, as the foundational
instrument in global tobacco control

OVERARCHING/ENABLING ACTIONS

Reducing modifiable risk factors for noncommunicable disease and underlying social
determinants through creation of health-promoting environments

7

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Increase excise taxes on alcoholic beverages1

• Enact and enforce bans or comprehensive restrictions on exposure to alcohol advertising
(across multiple types of media)2

• Enact and enforce restrictions on the physical availability of retailed alcohol (via reduced
hours of sale)2,3

• Enact and enforce drink-driving laws and blood alcohol concentration limits via sobriety
checkpoints4

• Provide brief psychosocial intervention for persons with hazardous and harmful alcohol
use5

• Carry out regular reviews of prices in relation to level of inflation and income

• Establish minimum prices for alcohol where applicable

• Enact and enforce an appropriate minimum age for purchase or consumption of alcoholic
beverages and reduce density of retail outlets

• Restrict or ban promotions of alcoholic beverages in connection with sponsorships and
activities targeting young people

• Provide prevention, treatment and care for alcohol use disorders and comorbid
conditions in health and social services

• Provide consumer information about, and label, alcoholic beverages to indicate, the
harm related to alcohol

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An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

Non financial considerations

1 Requires an effective system for tax administration and should be combined with efforts to prevent tax avoidance and tax
evasion

2 Requires capacity for implementing and enforcing regulations and legislation

3 Formal controls on sale need to be complemented by actions addressing illicit or informally produced alcohol

4 Requires allocation of sufficient human resources and equipment

5 Requires trained providers at all levels of health care

HARMFUL USE OF ALCOHOL

OVERARCHING/ENABLING ACTIONS

• Implement the WHO global strategy to reduce harmful use of alcohol through multisectoral actions in the
recommended target areas

• Strengthen leadership and increase commitment and capacity to address the harmful use of alcohol

• Increase awareness and strengthen the knowledge base on the magnitude and nature of problems caused
by harmful use of alcohol by awareness programmes, operational research, improved monitoring and
surveillance systems

8

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Reduce salt intake through the reformulation of food products to contain less salt and
the setting of target levels for the amouAnt of salt in foods and meals1

• Reduce salt intake through the establishment of a supportive environment in public
institutions such as hospitals, schools, workplaces and nursing homes, to enable lower
sodium options to be provided1

• Reduce salt intake through a behaviour change communication and mass media campaign

• Reduce salt intake through the implementation of front-of-pack labelling2

• Eliminate industrial trans-fats through the development of legislation to ban their use in
the food chain2

• Reduce sugar consumption through effective taxation on sugar-sweetened beverages

• Promote and support exclusive breastfeeding for the first 6 months of life, including
promotion of breastfeeding

• Implement subsidies to increase the intake of fruits and vegetables

• Replace trans-fats and saturated fats with unsaturated fats through reformulation,
labelling, fiscal policies or agricultural policies

• Limiting portion and package size to reduce energy intake and the risk of overweight/obesity

• Implement nutrition education and counselling in different settings (for example, in
preschools, schools, workplaces and hospitals) to increase the intake of fruits and vegetables

• Implement nutrition labelling to reduce total energy intake (kcal), sugars, sodium and fats

• Implement mass media campaign on healthy diets, including social marketing to reduce
the intake of total fat, saturated fats, sugars and salt, and promote the intake of fruits
and vegetables

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int

Non financial considerations

1 Requires multisectoral actions with relevant ministries and support by civil society

2 Regulatory capacity along with multisectoral action is needed

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UNHEALTHY DIET

OVERARCHING/ENABLING ACTIONS

• Implement the global strategy on diet, physical activity and health

• Implement the WHO recommendations on the marketing of foods and non-alcoholic beverages to children

9

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Implement community wide public education and awareness campaign for physical
activity which includes a mass media campaign combined with other community based
education, motivational and environmental programs aimed at supporting behavioural
change of physical activity levels *

• Provide physical activity counselling and referral as part of routine primary health care
services through the use of a brief intervention1

• Ensure that macro-level urban design incorporates the core elements of residential
density, connected street networks that include sidewalks, easy access to a diversity of
destinations and access to public transport2

• Implement whole-of-school programme that includes quality physical education,
availability of adequate facilities and programs to support physical activity for all children

• Provide convenient and safe access to quality public open space and adequate
infrastructure to support walking and cycling

• Implement multi-component workplace physical activity programmes

• Promotion of physical activity through organized sport groups and clubs, programmes
and events

* The wording has been updated from document A70/27 to fully align with the technical briefing entitled “Physical
inactivity interventions for the Appendix 3 of the WHO Global NCD Action Plan” which was made available to Member
States on 24 April 2017 as part of WHO’s effort to provide additional technical briefings on the evidence underlying the
best buys and other recommended interventions (see http://www.who.int/ncds/governance/appendix3-update/en/).

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

Non financial considerations

1 Requires sufficient, trained capacity in primary care

2 Requires involvement and capacity of other sectors apart from health

PHYSICAL INACTIVITY

OVERARCHING/ENABLING ACTIONS

• Implement the global strategy on diet, physical activity and health

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10

OVERARCHING/ENABLING ACTIONS

• Integrate very cost-effective noncommunicable disease interventions into the basic primary health care
package with referral systems to all levels of care to advance the universal health coverage agenda

• Explore viable health financing mechanisms and innovative economic tools supported by evidence

• Scale up early detection and coverage, prioritizing very cost-effective high-impact interventions including
cost-effective interventions to address behavioural risk factors

• Train the health workforce and strengthen the capacity of health systems, particularly at the primary care
level, to address the prevention and control of noncommunicable diseases

• Improve the availability of the affordable basic technologies and essential medicines, including generics,
required to treat major noncommunicable diseases, in both public and private facilities

• Implement other cost-effective interventions and policy options in objective 4 to strengthen and orient
health systems to address noncommunicable diseases and risk factors through people-centred health
care and universal health coverage

• Develop and implement a palliative care policy, including access to opioids analgesics for pain relief,
together with training for health workers

• Expand the use of digital technologies to increase health service access and efficacy for NCD prevention,
and to reduce the costs in health care delivery

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

Objective 4 : Strengthen and orient health systems to address the prevention and control of
noncommunicable diseases and the underlying social determinants through
people-centred primary health care and universal health coverage

11

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Drug therapy (including glycaemic control for diabetes mellitus and control of
hypertension using a total risk* approach) and counselling to individuals who have had
a heart attack or stroke and to persons with high risk (≥ 30%) of a fatal and non-fatal
cardiovascular event in the next 10 years1

> Drug therapy (including glycaemic control for diabetes mellitus and control of
hypertension using a total risk approach) and counselling to individuals who have
had a heart attack or stroke and to persons with moderate to high risk (≥ 20%) of a
fatal and non-fatal cardiovascular event in the next 10 years2

• Treatment of new cases of acute myocardial infarction** with either: acetylsalicylic
acid, or acetylsalicylic acid and clopidogrel, or thrombolysis, or primary percutaneous
coronary interventions (PCI)3

> Treatment new cases of acute myocardial infarction with aspirin, initially treated in a
hospital setting with follow up carried out through primary health care facilities at a 95%
coverage rate

> Treatment of new cases of acute myocardial infarction with aspirin and thrombolysis,
initially treated in a hospital setting with follow up carried out through primary health care
facilities at a 95% coverage rate

> Treatment of new cases of myocardial infarction with primary percutaneous coronary in-
terventions (PCI), aspirin and clopidogrel, initially treated in a hospital setting with follow
up carried out through primary health care facilities at a 95% coverage rate

• Treatment of acute ischemic stroke with intravenous thrombolytic therapy4

• Primary prevention of rheumatic fever and rheumatic heart diseases by increasing
appropriate treatment of streptococcal pharyngitis at the primary care level5

• Secondary prevention of rheumatic fever and rheumatic heart disease by developing a
register of patients who receive regular prophylactic penicillin

• Treatment of congestive cardiac failure with angiotensin-converting-enzyme inhibitor,
beta-blocker and diuretic

• Cardiac rehabilitation post myocardial infarction

• Anticoagulation for medium-and high-risk non-valvular atrial fibrillation and for
mitral stenosis with atrial fibrillation

• Low-dose acetylsalicylic acid for ischemic stroke

• Care of acute stroke and rehabilitation in stroke units

CARDIOVASCULAR DISEASES AND DIABETES

* Total risk is defined as the probability of an individual experiencing a cardiovascular diseases event
(for example, myocardial infarction or stroke) over a given period of time, for example 10 years.

** Costing assumes hospital care in all scenarios.

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

Non financial considerations

1 Feasible in all resource settings, including by non-physician health workers

2 Applying lower risk threshold increases health gain but also increases implementation cost

3 Selection of option depends on health system capacity

4 Needs capacity to diagnose ischaemic stroke

5 Depending on prevalence in specific countries or sub-populations

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12

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Preventive foot care for people with diabetes (including educational programmes,
access to appropriate footwear, multidisciplinary clinics)1

• Diabetic retinopathy screening for all diabetes patients and laser photocoagulation for
prevention of blindness 1

• Effective glycaemic control for people with diabetes, along with standard home glucose
monitoring for people treated with insulin to reduce diabetes complications 1

• Lifestyle interventions for preventing type 2 diabetes

• Influenza vaccination for patients with diabetes

• Preconception care among women of reproductive age who have diabetes including
patient education and intensive glucose management

• Screening of people with diabetes for proteinuria and treatment with angiotensin-converting
enzyme inhibitor for the prevention and delay of renal disease

DIABETES

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

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1 Requires systems for patient recall

13

BEST-BUYS AND OTHER RECOMMENDED INTERVENTIONS:

• Vaccination against human papillomavirus (2 doses) of 9–13 year old girls

• Prevention of cervical cancer by screening women aged 30 –49 years, either through:

> Visual inspection with acetic acid linked with timely treatment of pre-cancerous lesions1

> Pap smear (cervical cytology) every 3–5 years linked with timely treatment of
pre-cancerous lesions2

> Human papillomavirus test every 5 years linked with timely treatment of
pre-cancerous lesions3

• Screening with mammography (once every 2 years for women aged 50-69 years) linked
with timely diagnosis and treatment of breast cancer4

• Treatment of colorectal cancer stages I and II with surgery +/- chemotherapy and radiotherapy

> Basic palliative care for cancer: home-based and hospital care with multi-disciplinary
team and access to opiates and essential supportive medicines5

• Prevention of liver cancer through hepatitis B immunization

• Oral cancer screening in high-risk groups (for example, tobacco users, betel-nut
chewers) linked with timely treatment

• Population-based colorectal cancer screening, including through a faecal occult blood
test, as appropriate, at age >50 years, linked with timely treatment

An up-to-date list of WHO tools and resources for each objective can be found at http://www.who.int/nmh/ncd-tools/en

CANCER
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TOBACCO INDUSTRY
INTERFERENCE
A GLOBAL BRIEF

2

TOBACCO INDUSTRY
INTERFERENCE
A GLOBAL BRIEF

© World Health Organization 2012

All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased
from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857;
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or concerning the delimitation of its frontiers or boundaries.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended
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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the
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its use.

Image credits: Cover Fabrica; and pages 2 and 24.
Illustrations on pages 8–13: Yann Le Floch

Printed in France

Document number: WHO/NMH/TFI/12.1

3

TOBACCO INDUSTRY
INTERFERENCE
A GLOBAL BRIEF

4

5

Stop tobacco industry interference
in tobacco control

Curbing the tobacco epidemic

Tobacco addiction is a global epidemic that ravages entire countries and regions, wreaking the most
havoc in the most vulnerable countries and creating an enormous toll of disability, disease, lost
productivity and death. Tobacco use continues to be the leading global cause of preventable death.
It kills nearly 6 million people every year through cancer, heart disease, respiratory diseases,
childhood diseases and others. It also causes hundreds of billions of dollars of economic losses
worldwide every year. If current trends continue, by 2030 tobacco will kill more than 8 million people
worldwide every year, with 80% of these premature deaths occurring among people in low- and
middle-income countries. Over the course of the 21st century, tobacco use could kill up to a billion
people unless urgent action is taken.

We know what works to curb the tobacco epidemic. The action we need to take is laid out in the
WHO Framework Convention on Tobacco Control (WHO FCTC). So far, 173 nations (plus the
European Union) have pledged to work together to implement the Convention in order to protect
present and future generations from the devastating health, social, environmental and economic
consequences of tobacco consumption and exposure to tobacco smoke. However, these tobacco
control efforts are systematically opposed by the tobacco industry. Who or what is the tobacco
industry and what forms do its interference with public health efforts take?

“The tobacco epidemic is entirely man-made, and it can be turned around through the
concerted efforts of governments and civil society.”
Dr Margaret Chan, at the launch of the WHO Report on the global tobacco epidemic, 2008

“The enemy, the tobacco industry, has changed its face and its tactics.
The wolf is no longer in sheep’s clothing, and its teeth are bared.”

Dr Margaret Chan, Director-General of WHO, keynote speech,
15th World Conference on Tobacco or Health, Singapore, 20 March 2012

6

Tobacco industry opposition

What is the «tobacco industry»?
The “tobacco industry” includes manufacturers, importers and distributors of tobacco products and
processors of tobacco leaf – an entire group of businesses whose only goal is to make profits,
directly or indirectly, from tobacco products.

The tobacco industry has energetically promoted tobacco sales, despite knowing for decades that
tobacco use and exposure to secondhand tobacco smoke damaged people’s health. Despite a
promise to investigate and share all research findings with the public, made in 1954 (1), the tobacco
industry has hidden the facts from the public and continues to deny the full impact of tobacco
products in order to maintain profits and increase sales. Dependency on tobacco is engineered,
in the case of smoking, by careful, calculated formulations of more than 1000 chemical and other
ingredients (2,3). The tobacco industry sells a product that, unlike any other legal commercial good,
kills up to half its regular users when consumed as directed by the manufacturer.

“I want to remind governments in every country of the range and force of counter-tactics used
by the tobacco industry – an industry that has much money and no qualms about using
it in the most devious ways imaginable.” Dr Margaret Chan, at the launch of the WHO Report
on the global tobacco epidemic, 2008

The tobacco industry puts profits before people

There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public
health policy interests. In one corner, the tobacco industry produces and promotes a product that has
been scientifically proven to be highly addictive, to harm and kill many and to give rise to a variety of
social ills, including increased poverty. In the opposite corner, many governments and public health
workers try to increase the health of the population by implementing measures to reduce tobacco
use. The tobacco industry recognizes the impact of these measures and actively fights against these
efforts because of their negative effect on its sales. Time and time again, the industry has used its
resources to halt these public health policies where it can, water them down when it cannot stop
them altogether, and undermine their enforcement when they are adopted.

The tobacco industry has decades of experience of operating away from the public eye. Although
these covert tactics continue, in recent years tobacco industry opposition has become more
aggressive and overt. It increasingly includes direct counter-action against policies and strategies
contained in, and promoted by, the WHO FCTC (4). The objective is to extend the tobacco industry’s
sphere of influence with the aim of reaching all levels and sectors of government, as well as
nongovernmental groups including the private sector and civil society, while trying to appear before
politicians and the public as indispensable contributors to economic and social welfare.

7

“Tactics aimed at undermining anti-tobacco campaigns, and subverting the WHO Framework
Convention, are no longer covert or cloaked by an image of corporate social responsibility.
They are out in the open and they are extremely aggressive.” Dr Margaret Chan, keynote
speech, 15th World Conference on Tobacco or Health, Singapore, 20 March 2012

Forms of tobacco industry interference

In its efforts to derail or weaken strong tobacco control policies, tobacco industry interference takes
many forms. These include:

• manoeuvering to hijack the political and legislative process;

• exaggerating the economic importance of the industry;

• manipulating public opinion to gain the appearance of respectability;

• fabricating support through front groups;

• discrediting proven science; and

• intimidating governments with litigation or the threat of litigation.

8

In a presentation to the Philip Morris Board of Directors in 1995, the then Senior Vice-President
of Worldwide Regulatory Affairs of the company stated: “Our goal is to help shape regulatory
environments that enable our businesses to achieve their objectives … [fighting] aggressively
with all available resources, against any attempt, from any quarter, to diminish our ability to
manufacture our products efficiently, and market them effectively …” (5).

The range of strategies used by the tobacco industry, then and now, to influence the political
and legislative process includes conspiring with lobbyists to promote self-interested decisions in
preference to those that serve the public good. Existing evidence suggests, for example, that in
several countries the tobacco industry tried to undermine the country’s position in the negotiation
of the WHO FCTC and continues to attempt to derail the treaty’s implementation (6,7,8,9,10,11,
12,13,14). The tactics used by the tobacco industry included: the inciting of controversy between
financial, trade and other ministries on one side and the health ministry on the other side; the
use of business associations and other “front groups” to lobby on the industry’s behalf; and the
securing of industry access to the WHO FCTC negotiations through its well established links with
the International Organization for Standardization (15). Other evidence shows that the industry has
sought to weaken legislation in many countries in all regions of the world.

Manoeuvering to influence political and legislative decisions also involves: creating and exploiting
legislative loopholes; demanding a seat at government decision-making tables; promoting voluntary
regulation instead of legislation; and drafting and distributing sample legislation that is favourable to
the tobacco industry. There have been cases of industry representatives actually writing the language
of tobacco control and other legislation, to ensure that any regulatory measures would not be too
restrictive on the industry’s aggressive marketing practices (16,17).

Another common strategy is entering into industry partnerships with different branches of government
to fund joint projects, such as border patrols to prevent illicit trade, sports programmes for children,
support for meetings and events and sponsoring of meetings that play on human rights concerns
and condemn regulatory initiatives.(18, 19, 20). Other strategies include making political campaign
contributions, chalking up favours by financing government initiatives on other health issues and
defending trade benefits at the expense of health. All these strategies, along with the claims of
wanting “reasonable” regulation that is ineffective, give the industry constant access to individuals in
power and the potential to manipulate the policy-making process.

Manoeuvering to hijack
the political and

legislative process

9

The tobacco industry boosts its efforts to interfere in the political process by exaggerating its own
contribution, expressed in terms of employment, tax contributions and other economic indicators,
to the economy of a country, region, province or municipality. Not only is the economic information
over-hyped, but it also ignores the negative economic impact of tobacco use, including the drain on
the public purse caused by the need to treat the millions of people afflicted by diseases caused by tobacco.

The industry claims, for example, to generate a high level of direct and indirect employment.
It opposes tobacco control measures on the grounds that they would have a negative impact on
employment and therefore on the country’s economy. Using this argument, the industry lobbies
against tobacco tax increases, predicting catastrophic consequences for its business. In reality,
evidence has shown, at least to date, that job losses in the tobacco sector have little to do with
stricter tobacco control measures. A recent publication (21) highlights how the tobacco industry
lobbied against cigarette taxation and tariffs on the pretext that reduced production costs would
preserve jobs. Despite obtaining tax advantages, the industry still reorganized and consolidated its
production processes, leading to job losses in the sector. In fact, even if its demands are met, it is not
uncommon for the industry to threaten to close a factory or department and move elsewhere, despite
its claims to social commitment and responsibility.

Sound economic studies show that industry claims of potential job and other economic losses
resulting from stricter tobacco controls are significantly overstated anyway; in fact, these losses are
negligible. If consumption declines, job losses in tobacco-dependent sectors, are more than offset by
increases in employment in other sectors with no negative impact on the overall economy (22).

Exaggerating
the economic importance

of the industry

10

Public opinion governs the workings of our society, and the tobacco industry devotes considerable
resources to trying to twist it. The industry is aware that the views of millions of people every day are
influenced by the mass media. The tobacco industry uses public relations firms and other groups to
concoct and spin the news to promote its lethal business. Public relations firms have often been used
in an attempt to manipulate the media and public opinion about various aspects of tobacco control
and to gather the support of persons who oppose government “intrusion” in business and taxation,
thus instigating general antiregulatory and antigovernment views.

However, the main way of manipulating public opinion is corporate social responsibility (CSR)
activity, also known as “social investment”. While CSR activities in many industries reflect an honest
commitment to behave ethically and contribute to economic development, while improving the quality
of life of the workforce, the local community and society at large, for the tobacco industry it is a
self-serving strategy. CSR activities by the tobacco industry may include ineffective youth smoking
prevention campaigns which allow the industry to present itself as “caring” for the very youngsters
to whom it also markets its deadly products. The industry takes pains to support social programmes
for tobacco growers and their children and unrelated social causes such as programmes to combat
domestic violence against women, disaster relief efforts and environmental causes and groups.
Every time a group accepts funds from or works with the tobacco industry, the industry claws back
some of the respectability it has lost through the social, economic, environmental and health damage
caused by its products. In summary, the tobacco industry uses CSR to claim that it cares for society
and the environment and to present itself as a responsible member of society.

These CSR efforts interfere with health policy by winning goodwill for the industry among politicians
and the public. The industry uses CSR to seduce groups not related to tobacco – sometimes not
even related to health – into becoming industry allies. In this way, when there are attempts to
regulate tobacco marketing, for example, the industry can call on a host of organizations which are
well disposed towards it, or in its debt, to speak on its behalf.

This phenomenon has recently been seen in countries from regions as diverse as Africa (23)
and Europe (24), where representatives of tobacco companies complained that a proposed ban on
sponsorship, a recognized form of marketing, was harmful and unnecessary. A chorus of protests
from charities supporting causes such as mental health and care for the elderly was then quoted in
the media and presented as opposition to proposed legislation banning tobacco marketing. Media
reports focused on the loss of income for the charitable organizations, and not on the health gains
to be made by restricting tobacco marketing.

Manipulating public opinion
to gain the appearance

of respectability

11

Years of deception have so isolated the tobacco industry from business and citizens that it needs
to simulate support. To this end, the industry uses front groups. Front groups are organizations
that purport to serve a public cause while actually serving the interests of a third party, sometimes
obscuring or concealing the connection between them. The tobacco industry uses phony “grassroots”
groups to give an impression of social support for its interests, typically “smokers’ rights” groups,
“citizens’ rights” groups and business groups.

“Smokers’ rights” groups are created and promoted behind the scenes to preserve the social
acceptability of smoking and speak out for allowing smoking in public places. Philip Morris proposed
adopting a variety of personas: “Sometimes we will need to speak as independent scientists,
scientific groups and businessmen; at other times we will talk as the industry; and, finally, we will
speak as the smoker” (25). Since smoke-free policies are widely supported by the general public,
the “smokers’ rights” groups try to maintain a “controversy” about secondhand smoke in the social
arena and focus the debate on the smoker rather than the tobacco industry or the harmful effects
of the smoke itself. “Smokers’ rights” groups oppose clean indoor air laws and policies, and take a
stand on other issues as well, such as tobacco taxes and advertising bans (26).

Business front groups are used to argue that tobacco control policies cause economic damage to
the businesses they claim to represent. The tobacco industry is known for funding tobacco growers’
associations and creating or funding restaurant or bar organizations to oppose smoke-free measures
in the hospitality sector. Their role is to insist that banning smoking would cost them business and to
create an aggressive mentality in legitimate restaurant and bar operators against government smoke-
free policies. The tobacco industry has also created front groups to oppose consumer regulation,
depicting it as an attack on individual freedom. It describes these regulation efforts as part of the
“nanny culture” led by a “growing fraternity” of food and anti-tobacco “cops”, “health care enforcers”,
“anti-meat activists” and “meddling bureaucrats” who “know what’s best for you” (27).

Fabricating support
through front groups

12

The scientific evidence about the harm caused by tobacco and secondhand smoke is so strong and
extensive that the industry needs to discredit it in order to get around or weaken tobacco control
legislation. “Doubt is our product”, a cigarette executive once observed, “since it is the best means
of competing with the ‘body of fact’ that exists in the minds of the general public. It is also the means
of establishing a controversy” (28).

The efforts of the tobacco industry to deny the lethal effects of secondhand smoke are well known.
For decades the industry has known that secondhand smoke is toxic. One company, for example,
privately performed extensive research on secondhand smoke in a secret laboratory and
demonstrated its toxicity (29,30). It then designed a global programme with other tobacco companies,
hiring scientists and lobbyists to dispute scientific evidence about health risks. The industry hired
scientists and briefed journalists, government officials and members of the scientific community in
order to keep them confused about the hazards posed by tobacco and secondhand smoke.
The majority of tobacco companies continue to deny that secondhand smoke kills (31,32).

Whether it is creating confusion about the harms of secondhand smoke, the addictiveness of
nicotine or the deleterious effects of smoking, the tobacco industry’s duplicitous tactics have spawned
a multimillion-dollar industry which dismisses research conducted by the scientific community as
“junk science”. Hired consultants have increasingly tried to skew the scientific literature, and have
manufactured and magnified scientific uncertainty, in order to divert policy decisions to the industry’s
advantage. In doing so, they have not only delayed action on tobacco control, but have weakened
public health safeguards and put up barriers which make it harder for lawmakers, government
agencies and courts to respond to future threats.

Discrediting proven science

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An often-used threat, increasingly carried out, is the threat of legal retaliation against a specific policy
or set of policies. This can be at any level, from global to local. The tobacco industry, employing a
veritable army of lawyers, threatens legal action against governments over tobacco control policies
that threaten its profits. Legal arguments often question the constitutionality of any policy measure
or legislation, claim that due process was not followed in the phase that preceded the adoption of
legislation and argue against any implementation or regulatory language that follows adoption.

Since the entry into force of the WHO FCTC, domestic legal challenges by the tobacco industry and
its front groups have more and more frequently failed, as courts cite the treaty as the legal
foundation for strong tobacco control legislation. Recently, the industry has shifted its litigation
strategy, scaling up the use of international bilateral or multilateral agreements to challenge a
country’s tobacco control policy in the courts. For example, the tobacco industry has recently brought
actions against Australia, Norway, Uruguay and other countries which have introduced tougher
tobacco control measures in line with the WHO FCTC. The industry has pursued these governments
through international mechanisms and using bilateral investment agreements. It seems that these
intimidation tactics are deliberately designed to deter other countries from introducing similar tobacco
control measures (33).

Intimidating governments
with litigation or

the threat of litigation

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Tobacco industry interference: always and everywhere a threat
to public health

Regardless of the shape or form it takes, tobacco industry interference is always designed to thwart
attempts to curb the tobacco epidemic and its negative social, economic, environmental and health
consequences. While there is a growing awareness of the tobacco industry’s unceasing attempts to
sabotage public health, it is less well known that tobacco companies often work hand in glove with
their commercial competitors to keep regulation to a minimum and obtain advantageous conditions
from the government to help them run their businesses.

Three things to keep in mind about tobacco industry interference:

• it is not always obvious;

• it is not always in the area of tobacco control; and

• it is not always even in the area of health.

Tobacco industry interference is a threat to public health, whether the industry is private or state-
owned. So all countries need to be aware and take action against tobacco industry interference.
WHO recognizes that the tobacco industry uses backhanded methods to thwart tobacco control ef-
forts, and urges governments to remain:

“… alert to any efforts by the tobacco industry to continue its subversive practice and to assure
the integrity of health policy development in any WHO meeting and in national governments.”
(World Health Assembly resolution WHA54.18, 2001) (34)

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How to beat tobacco industry interference

Fortunately, to address this global threat there is a global solution. A total of 173 countries plus
the European Union (comprising almost 90% of the world’s population) have already agreed to
implement an international treaty, the WHO FCTC, that sets out policies aimed at controlling this
epidemic of disease, death and suffering. Countries that are Parties to this treaty recognize the
tobacco industry as a major barrier to achieving global health and have committed themselves to
overcoming this barrier, as shown by Article 5.3 of the treaty (35).

WHO Framework Convention on Tobacco Control, Article 5.3

“In setting and implementing their public health policies with respect to tobacco control,
Parties shall act to protect these policies from commercial and other vested interests of
the tobacco industry in accordance with national law.”

Because the industry interferes in all countries, those countries that are not yet a Party to the WHO
FCTC are also urged to counteract the industry’s malicious interference and refuse to provide it with
a safe haven for its business and litigation.

Everyone can help. Governments, nongovernmental organizations, academia and individual citizens
can all act to put an end to tobacco industry interference.

Governments must act to protect public health from tobacco
industry interference

All the Parties to the WHO FCTC have agreed on ways to stop tobacco industry interference.
They have adopted Guidelines for the implementation of Article 5.3 of the WHO FCTC (36),
based on four principles:

Principle 1:
There is a fundamental and irreconcilable conflict between the tobacco industry’s interests
and public health policy interests.

Principle 2:
Parties, when dealing with the tobacco industry or those working to further its interests,
should be accountable and transparent.

Principle 3:
Parties should require the tobacco industry and those working to further its interests to operate
and act in a manner that is accountable and transparent.

Principle 4:
Because their products are lethal, the tobacco industry should not be granted incentives
to establish or run their businesses.

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Based on these principles, governments should take action to prevent tobacco industry interference
in tobacco control and public health. They should communicate information relevant to the tobacco
industry to policy-makers, decision-makers and stakeholders and establish coordinated approaches
involving all sectors of the government to promote full accountability and guide all interactions with
the tobacco industry, ensuring that these interactions are limited to what is strictly necessary and
transparently disclosed. A monitoring system for the tobacco industry, with relevant exchanges of
information at regional and global level, should be considered as an important tool to implement the
Article 5.3 guidelines.

More specifically, in applying the Article 5.3 guidelines, governments should:

• Raise awareness about the addictive and harmful nature of tobacco products and about
tobacco industry interference with tobacco control policies.

• Establish measures to limit interactions with the tobacco industry and ensure the transparency
of those interactions that do occur.

• Reject partnerships and non-binding or non-enforceable agreements with the tobacco industry.
Not accept funds or help from the tobacco industry. Not support or endorse tobacco
industry attempts to organize, promote, participate in or implement youth, public education or
other initiatives that are directly or indirectly related to tobacco control.

• Require that information provided by the tobacco industry be transparent and accurate.
Require the tobacco industry and those working to further its interests to submit regular,
truthful, complete and precise information on tobacco production, manufacture,
market share, marketing expenditures, revenues or any other activity, including lobbying,
philanthropy and political contributions, as well as the disclosure or registration of tobacco
industry entities, affiliated organizations and individuals acting on their behalf, including lobbyists.

• Denormalize and, to the extent possible, regulate activities described as “socially responsible”
by the tobacco industry, including but not limited to activities described as “corporate social
responsibility”.

• Avoid giving preferential treatment to the tobacco industry.

• Treat state-owned tobacco companies in the same way as the rest of the tobacco industry.

• Avoid conflicts of interest for government officials and employees. Governmental action in this
area should include:

– mandating policy on the disclosure and management of conflicts of interest, binding on all
government officials, employees, consultants and contractors;
– implementing a code of conduct for public officials which prescribes the standards
with which they should comply in their dealings with the tobacco industry;
– prohibiting contributions by the tobacco industry or any entity working to further its interests to
the coffers of political parties, candidates or campaigns, or at least requiring full disclosure of
such contributions.

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Nongovernmental groups and academia need to monitor and
denounce interference
Nongovernmental groups and academia have an essential role in implementing the WHO FCTC and
Article 5.3 guidelines. In fact, any institution can help to counteract tobacco industry interference.
Here are some possible actions:

• Identify the potential allies and …

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