The global tobacco control movement is more than three decades old, but its impact is inconsistent. For every city or nation that takes strong action to reduce tobacco use, there is another where little if anything has been done to help people stop smoking or to establish tobacco control policies opposed by powerful tobacco industries. Tobacco continues to kill and cause debilitating illnesses, severely retarding progress in improving local, national, and global health and economic conditions. Recent data indicate that smoking is the leading cause of deaths from cardiovascular diseases (1.69 million deaths annually), cancer (1.4 million deaths), and chronic obstructive pulmonary diseases (970,000 deaths). About 1.25 billion people smoke cigarettes, representing more than one-sixth of the Earth’s population. According to reports from the World Cancer Congress and the 13th World Conference on Tobacco OR Health, held in Washington, D.C., in July 2006, if current trends hold, tobacco will kill a billion people in the 21st century, 10 times the toll it took in the 20th century. These sobering statistics are counterbalanced by some good news. In numerous countries, public health officials, civil society organizations, and various other advocacy groups have joined forces to initiate policies and programs designed to reduce tobacco use. Most comprehensive efforts have included a mixture of awareness raising; restrictions on the sale, promotion, and place of use of tobacco products; and taxes and laws that affect the price and availability of these products. A major milestone was achieved when the landmark Framework Convention on Tobacco Control (FCTC), a global treaty initiated by the World Health Organization (WHO), entered into force on February 27, 2005. As of the end of March 2007, a total of 168 countries had signed the treaty, and 146 of those had ratified it. Parties to the FCTC are expected to create national action plans to meet the treaty’s minimum requirements in areas such as tobacco advertising, access to smoking cessation programs, the size of warnings on cigarette packs, and the creation and enforcement of smoke-free public spaces. Wealthier countries have more potential resources at their disposal to implement tobacco control policies, yet there are plenty of examples—some of which are examined in this report’s case studies—of innovative and increasingly successful tobacco control efforts in resource-limited places. Central and Eastern Europe and Central Asia, however, remain in dire need of more extensive tobacco control. According to the World Health Organization, tobacco related diseases kill more than 700,000 people a year in the region and nearly 40 percent of middle-aged men die prematurely as a result of tobacco use. In some Eastern European countries, lung cancer mortality rates in men are the highest ever recorded anywhere in the world. The WHO has concluded that tobacco use is the major preventable cause of poor health in the region—and that comprehensive tobacco control is the best investment in health reform. Policymakers have been listening. By 2006, all Central and Eastern European countries and a majority of those in the former Soviet Union had enacted some tobacco control legislative and policy measures. However, many legislative regulations and national tobacco control programs, especially in the less developed countries farther east, are not effectively enforced and still have serious loopholes that prevent them from meeting WHO standards. One common thread has been the leadership of civil society groups in devising, implementing, and demanding the enforcement of tobacco control policies and regulations. Local nongovernmental organizations often have been among the first entities of any kind to advocate for tobacco control in their countries, including accession to the FCTC. Many of these civil society groups have received support from the Open Society Institute (OSI), which first provided grants for tobacco control in 2002. Among OSI’s most successful grantees is Poland’s Health Promotion Foundation (HPF), which since 1991 has played a leading role in lowering the burden of smoking-related diseases through tobacco control in its home country. Recently, HPF began planning the development of a regional center for tobacco control to enable the sharing of information and expertise on tobacco control throughout the region. Based in Warsaw, the Regional Tobacco Control Network and Center (RTCNC) is expected to be fully operational by the end of 2007. The case studies in this report document the advocacy efforts of NGOs in four countries expected to participate significantly in such regional engagement. The nations—Kazakhstan, Moldova, Romania, and Ukraine—are at different stages in tobacco control. The activities of these civil society groups represent a range of strategies reflecting the opportunities, obstacles, and expectations unique to their own nations and circumstances. Taken together, though, the case studies offer important lessons for future tobacco control efforts anywhere in the world. No matter where they live, committed activists generally are able to utilize even a small amount of funding to initiate a process of change; the success of their efforts is multiplied many times over with each increase in resources and capacity. Local leadership of this sort is essential to reversing the current trends in tobacco use, illness, and death that place millions of people at risk. Among the notable lessons are the following: Civil society is crucial to successful tobacco control efforts. The Polish experience in the early 1990s is instructive. After restrictions were lifted on civil society, groups pushed for greater openness about all political, economic, and social issues—including health. Tobacco control efforts gained momentum and policy reforms soon followed, including tobacco control legislation and improved public- and private-sector services designed to raise awareness and promote healthy lifestyles. Experience elsewhere reinforces the strong correlation between comprehensive tobacco control and engaged, fully independent civil societies. Effective tobacco control efforts require comprehensive, multipronged approaches and strategies. Given the power and influence of the tobacco industry in most countries, tobacco control advocates must continually seek to broaden the ways in which they raise awareness of tobacco’s negative medical, social, and financial consequences. Important strategies include extensive media campaigns; expanding coalitions within civil society and with government partners; directly challenging policymakers to publicly justify their opposition to tobacco control or reluctance to make it a priority; and collecting and disseminating solid health data, such as the number of deaths and hospitalizations due to tobacco-related illnesses. Economic research is an important, yet often neglected, component of effective advocacy. Policymakers and the general public are often unaware of the massive financial costs to society of tobacco use. Tobacco-related sickness and premature death reduce economic productivity in ways that can be quantified through rigorous data collection. Disabling tobacco-related conditions also force a redirection of individual and public resources from investment and savings—needed to help grow economies and raise living standards—to health care. Tax policies can be used to raise revenues for health promotion activities that lead to a reduction in tobacco-related health care costs. For example, several European countries and U.S. states have raised cigarette taxes and earmarked a portion of the higher revenues specifically for tobacco control activities, such as education and media campaigns. Enshrining health promotion earmarks in laws or government policies improves the likelihood of withstanding tobacco industry pressure to counter comprehensive tobacco control efforts. Media can be a powerful tool for and ally of tobacco control advocates. Tobacco control advocates in Kazakhstan invited members of the media on several tours of Almaty, pointing out violations of the national antitobacco law. The resulting newspaper articles and television coverage helped prompt local officials to introduce the “Smoke-free Almaty†initiative. Such effective use of media is relatively rare in the region. Civil society groups need to train in media advocacy and to share successful strategies and experiences more consistently. Tobacco control regulations and affordable “quit smoking†services are equally important in reducing tobacco use. Restrictions are far more effective in reducing tobacco use when accompanied by health promotion campaigns and accessible, affordable services to help people quit smoking. Incentives for changing behavior must be based on recognition of the medical and psychological elements of tobacco addiction. On their own, punitive measures rarely make an impact on complex behaviors that require extensive treatment and support. Expanded regional learning and cooperation offer clear benefits to local tobacco control efforts. Strategies used successfully in one country or context can have similarly positive impacts elsewhere. Expertise should be tapped more effectively through greater sharing of information and resources across the region, down to the grassroots level. Regional cooperation will also help sustain and expand civil society advocacy that has already shown great promise for improving health. The creation of the Regional Tobacco Control Network and Center should help facilitate such efforts.
