Around 300 million more people are now protected by at least one tobacco control measure than in 2007, but e-cigarettes and tobacco industry interference threaten achievements.
PAHO
Washington, DC,
15 August 2022 (PAHO)
Executive Summary by
Joaquim Cardoso MSc.
Health Systems Transformation — HST Institute
August 15, 2022
Some 900 million people, or 96% of the population of the 35 countries of the Americas are currently protected by at least one of the six tobacco control measures recommended by the World Health Organization (WHO), up 50% from 2007. However, progress has not been uniform.
According to the Report on Tobacco Control for the Region of the Americas 2022, presented today by the Pan American Health Organization (PAHO), 26 of the Region’s 35 countries have achieved the highest level of application of at least one measure; but other measures such as increased tobacco taxes have made slow progress and nine countries have not yet taken any action.
“Tobacco causes nearly a million deaths in the region every year and it is the only legal consumer product that kills up to half of those who use it,” said Dr. Anselm Hennis, Director of PAHO’s Department of Noncommunicable Diseases and Mental Health. “The response to this enormous threat must be equally aggressive. Control measures work and we must move more quickly to implement all of them.”
The report shows that, in 2021, of 35 countries in the Americas:
- 24 are implementing measures to protect against exposure to second-hand smoke
- 22 require large graphic warnings about the dangers of smoking on tobacco product packages
- 10 have surveillance systems with recent, periodic, and representative data on tobacco use by adults and young people
- 6 offer a comprehensive system to help people quit smoking
- 9 establish total bans on tobacco advertising, promotion, and sponsorship
- 3 apply indirect taxes to cigarettes that account for 75% or more of the retail price.
Progress in the application of the six measures known as MPOWER, established by WHO in 2008, has helped reduce the prevalence of tobacco use from 28% of the region’s population in 2000 to 16.3% in 2020, the second lowest in the world. In 2020, South America became the first smoke-free subregion of the Americas, where smoking is absolutely prohibited in enclosed public places, in workplaces, and on public transport.
Tobacco use is the leading risk factor for six of the eight leading causes of death in the world, and for the four most preventable and prevalent noncommunicable diseases: cardiovascular disease, diabetes, cancer, and chronic respiratory disease. All forms of tobacco are harmful and there is no safe level of exposure.
Addressing the threat of new products
The PAHO report warns that new and emerging nicotine and tobacco products such as e-cigarettes are becoming increasingly available and accessible, posing a threat to tobacco control. It also warns that the tobacco industry makes misleading claims to increase consumers and enter new markets.
PAHO/WHO recommends that governments put regulations in place to help prevent non-smokers from starting to use these products, to prevent tobacco use from becoming socially acceptable again, and to protect future generations.
Currently, the sale of electronic nicotine delivery systems is banned in seven countries in the Americas.
Five of these countries and 13 others have taken partial measures to prohibit the use of these systems, limit their advertising, promotion, and sponsorship, and require warnings on their packaging.
Fifteen countries do not impose any regulatory framework.
Report on Tobacco Control for the Region of the Americas 2022
Executive Summary
Overview
Tobacco control is highly relevant for accelerating progress toward the United Nations Sustainable Development Goals given the burden tobacco products place on health, the economy, the environment, and societies in general. Tobacco remains the only legal consumer product that kills up to half of those who use it as intended by the manufacturers and is a risk factor for the four most prevalent noncommunicable diseases worldwide.
Globally, tobacco accounts for more than 8 million deaths annually, of which 7 million deaths are the result of direct use, while around 1.2 million are the result of non-smokers being exposed to second-hand smoke.1 Since monitoring of the progress of tobacco control began, approximately 13 years ago, heralded by the publication of the first World Health Organization (WHO) Report on the Global Tobacco Epidemic in 2008, notable milestones, both worldwide and regional, have been recorded.
The present Report on Tobacco Control for the Region of the Americas 2022 provides a detailed overview of the status of tobacco control within the Region of the Americas for the measures contained in the WHO MPOWER package: monitoring the prevalence of tobacco use and tobacco control policies (M), protection from exposure to tobacco smoke (P), offer help to quit (O), warn about the dangers of tobacco (W), enforce bans on tobacco advertising, promotion, and sponsorship (E), and raise taxes on tobacco products (R).2
The Region of the Americas saw a decrease in the prevalence of current tobacco consumption from 28% in 2000 to 16.3% in 2020, ranking the second lowest prevalence of current tobacco consumption in the world. Along with the WHO European Region, the Americas also shows the smallest difference in the prevalence of current tobacco consumption between adult males and females. In the Americas, the ratio of men to women is 1.9 (21.3% men and 11.3% women) compared with the global ratio of 4.7 (36.7% men and 7.8% women), reaffirming the need for the Region to strengthen the gender aspect of tobacco control policies and strategies. In 2020, the prevalence of current tobacco use in adults continued to be highest in Chile (29.2%) and lowest in Panama (5.0%), when taking into account the number of countries with comparable, age-standardized data.
Regarding the youth population (individuals aged 13 to 15 years), among the 35 Pan American Health Organization (PAHO) Member States Brazil reported the lowest prevalence (6.9%) while Dominica reported the highest prevalence (25.3%). According to the 2021 WHO Global Report on the Trends in Prevalence of Tobacco Use 2000–2025, 4th edition,3 the average proportion of the population consuming tobacco in the Region of the Americas is 11.3% compared with the global average of 10.3%. Of the 26 countries in the Region with information about electronic cigarettes (e-cigarettes), the United States of America has the highest prevalence of current consumption of e-cigarettes by young people in the Region (19.6%), and Brazil has the lowest (0.2%). In all countries with available data, e-cigarette use is most prevalent among male adolescents, with the exception of Venezuela (Bolivarian Republic of) and Colombia, where the prevalence of e-cigarette use is almost equal among young females and males.
The Region of the Americas is on track to achieve Goal 5 of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020, which stipulated a relative reduction of 30% in the prevalence of tobacco use among individuals aged 15 years and older. The Region is expected to record a 14.9% prevalence in current tobacco use and, based on estimates from current trends, it is likely a regional prevalence of 14.3% will be achieved, thereby exceeding the goal of a relatGlobally, the number of countries in the world that have adopted at least one measure of the MPOWER package at the highest level of implementation has increased from 44 countries in 2008 to 146 countries in 2020, covering more than 5 billion of the world’s population. 5
There are now 101 countries classified as having attained the highest level of application with respect to health warnings on tobacco products (covering 60% or 4.7 billion of the world’s population). The W measure of the MPOWER package has the highest population coverage as well as the highest number of countries implementing this measure, with 17 of these countries adopting legislation that mandates plain packaging for tobacco products. Increasing tobacco prices through taxation remains the policy with the lowest population coverage, at 13%, with no recorded increase since 2018.
In total, 26 of the 35 countries of the Region have achieved the highest level of application of at least one measure of the MPOWER technical package, representing a population coverage of 96% (Figure ES1). Regarding the implementation of measure P at the highest level of application, as of 31 December 2021, the Americas has the highest number of countries doing this compared with the other WHO regions (24 out of 35, 23 of which are Parties to the WHO FCTC). It is noteworthy that this Region has had the largest number of Member States implementing this measure at the highest level of application since the 2009 edition of the WHO Report on the Global Tobacco Epidemic. The number of countries implementing measure W at its highest level of achievement has increased to 22, with various countries implementing other measures at their highest level of application: measure M (10 countries), measure O (6 countries), measure E (9 countries), and measure R (3 countries)
Key findings and conclusions
The Region of the Americas is expected to record a 14.9% prevalence of tobacco consumption by 2025, which signifies that the Region is on track to achieve Goal 5 of the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020; i.e., a 30% relative reduction in the prevalence of tobacco use among individuals aged 15 years and older Ten countries within the Region have surveillance systems with recent, periodic, and representative data for tobacco consumption in adult and youth populations, resulting in 65% of the regional population covered by tobacco consumption monitoring policies at the highest levels of achievement. Nevertheless, five Member States (Barbados, Belize, Dominica, Haiti, and Saint Kitts and Nevis) do not have recent representative data for the prevalence of tobacco use in adults and youths.
The Region has the highest number of Member States implementing the P measure at the highest level of application compared with other Regions globally, since the 2009 edition of the WHO Report on the Global Tobacco Epidemic (Table ES1). Since 2018, five countries have enacted comprehensive smoke-free policies to bring the total to 24 countries within the Region implementing measures to protect people from exposure to second-hand smoke at the highest level of application.
The ascension of Paraguay to a smoke-free Member State in 2020 heralded South America becoming the first smoke-free subregion within the Region (Table ES2).
Just six Member States (Brazil, Canada, El Salvador, Jamaica, Mexico, and the United States of America) have established national toll-free quitlines, accessible nicotine replacement therapy, and cessation support services offered to the population, thereby enabling them to implement measures related to offer help to quit tobacco at the highest level of application (Table ES2).
There are 22 countries now implementing measures to warn about the dangers of tobacco through graphic health warnings on the packaging of tobacco products, after the United States of America joined the group in 2020, preceded by Antigua and Barbuda in 2018, and Honduras in 2017. In 2019, Uruguay and Canada enacted policies that now mandate plain packaging of tobacco products (Table ES2).
Antigua and Barbuda (2018), Venezuela (Bolivarian Republic of) (2019), and Mexico (2021) now have comprehensive bans on the advertising, promotion, and sponsorship of tobacco products (TAPS). This brings the total to nine countries in the Region of the Americas that implement measures relating to TAPS at the highest level of application. A total of 21 Parties to the Framework Convention on Tobacco Control (WHO FCTC) within the Region have since passed the five-year deadline established for implementation of this measure (Table ES2).
Just three countries are implementing measures to ensure that the threshold of total indirect taxes represents 75% or more of the retail price of tobacco products (Table ES2).
and 13); ratification of the FCTC and the Protocol to Eliminate Illicit Trade in Tobacco Products by the Member States that have not yet done so; and strengthening Member States’ capacity in terms of public health policies to counter attempts at interference by the tobacco industry and those who work to further its interests (Article 5.3). Thus far, during the implementation of the mandates of the Strategy, there has been significant progress in many areas of tobacco control; however, it is likely that the targets established through these strategic lines of action will not be achieved when the life of the Strategy expires at the end of 2022.
Novel and emerging products such as e-cigarettes (electronic nicotine and non-nicotine delivery systems, ENDs and ENNDS) and heated tobacco products (HTPs) are becoming more widely available and accessible, thereby posing a threat to tobacco control. The tobacco and related industries employ various strategies to market these products as having reduced risk and claim they are effective cessation aids in a bid to provide a “solution” to the tobacco epidemic; however, in reality this is just a ploy to continue their existence and hook new users to maintain their markets.
Regarding ENDS/ENNDS, as early as the sixth session of the Conference of the Parties (COP6) to the WHO FCTC, Decision FCTC/ COP6(9)7 invited Parties to consider “Prohibiting or regulating them, including as tobacco products, medicinal products, consumer products, or other categories, as appropriate, taking into account a high level of protection for human health.” This advocacy has continued in successive COP sessions and, to date, within the Region of the Americas, seven countries have banned the sale of e-cigarettes. However, as the ban on sales does not eliminate the possibility of these products entering the market illegally, five of these countries have also opted to regulate their use to be consistent with legislation on smokefree environments or on TAPS. Eighteen countries have regulated the sale, use, and advertising of ENDS/ENNDS, 11 regulate them as tobacco products or tobacco related product, six regulate them as consumer products, and three regulate them as therapeutic products. Fifteen countries do not impose any form of regulatory framework.
As per Decision FCTC/COP8(22) of the eighth session of the Conference of the Parties to the WHO FCTC,8 “heated tobacco products are tobacco products and are therefore subject to the provisions of the WHO FCTC.” Parties were reminded “to regulate, including restrict, or prohibit, as appropriate, the manufacture, importation, distribution, presentation, sale and use of novel and emerging tobacco products, as appropriate to their national laws, taking into account a high level of protection for human health.” To date, 3 countries within the Region have banned the sale of HTPs, 25 regulate them as tobacco products, and 7 countries do not have any regulatory mechanisms in place for this category of products.
The recent COVID-19 pandemic has posed a further threat to the progress made in tobacco control, as the illness itself has worse outcomes for individuals living with noncommunicable diseases, including those who have risk factors for noncommunicable diseases, especially tobacco use. The pandemic also provided an opportunity for the tobacco industry to interfere with existing tobacco control policies in a bid to weaken them while attempting to improve the image of the industry as one that is socially responsible and caring.
It is evident that there has been significant progress made in advancing the tobacco control agenda within the Region, although challenges that can impede this progress will always appear. Therefore, countries must reiterate their commitments to remain steadfast and vigilant and to place public health as a priority to ensure that their people are protected from the dangers of tobacco. PAHO stands committed to supporting countries in achieving these targets.
Selected images
Suggested citation:
Pan American Health Organization. Report on Tobacco Control for the Region of the Americas 2022. Washington, DC: PAHO; 2022. Available from: https://doi.org/10.37774/9789275125892.
About the authors
This report was prepared under the general supervision of Rosa Sandoval, Regional Advisor, Tobacco Control and Economics of NCDs, of the Department of Noncommunicable Diseases and Mental Health (NMH) of PAHO.
Kavita Singh and Adriana Bacelar Gomes coordinated the preparation of this report and wrote most of the content.
Kavita Singh led the collection and analysis of data for the Americas published in the WHO Report on the Global Tobacco Epidemic, 2021, the main source of data for this publication.
Adriana Bacelar Gomes provided input on the overall structure of the report and contributed the data and information about surveillance systems, as well as reviewing the text and preparing the annexes contained within this publication.
Diana Ceron collaborated in the drafting of the chapters and assisted with providing input to the overall structure of the report.
Luciana Severini assisted in the review of the data on e-cigarettes and heated tobacco products.
Sehr Malik, Tatiana Villacres, Mercedes Carballo, and Gilberto Morales provided input in reviewing and crosschecking the information contained within the report.
The maps were prepared by Ramón Martínez. Julia Perry and Arantxa Cayon coordinated the editorial review and the communication details regarding the launch of this report.
PAHO especially thanks Martin Mariotta of the Center for International Cooperation on Tobacco Control (CICTC), Uruguay, for the preparation of the country summary profiles and tax fact sheets.
