The inexorable rise in global deaths from tobacco is increasingly driven by trends in low-income and middle-income countries (LMICs)1 where, by 2030, it is estimated that 6·8 million of the 8·3 million tobacco-related deaths will occur.2 The changing global patterns of tobacco use that underpin these mortality trends reflect the presence and actions of the tobacco industry, whose role in expanding tobacco use globally3, 4, 5 has led to its label as the vector of the tobacco epidemic.
In recognition that the factors driving the tobacco epidemic, notably the actions of the tobacco industry, transcend national borders, WHO used its treaty-making powers for the first time in developing the Framework Convention on Tobacco Control (FCTC). Given overwhelming evidence of the tobacco industry's efforts to subvert public health policy making,6 the treaty includes Article 5.3, which requires parties to protect their public health policies from the “vested interests of the tobacco industry”.7 The FCTC, which is legally binding, entered into force in 2005 and, by December, 2014, 180 of the UN's 193 member states were Parties to the Treaty. Yet FCTC implementation has been slow and uneven in large part because of tobacco industry efforts to subvert progress in tobacco control.8
In this final paper in a three-part Series on a tobacco-free world, we provide an overview of tobacco industry practices focusing on LMICs given three factors: first, the growing importance of LMICs to the tobacco industry's future; second, the increasing tobacco-related disease burden faced by LMICs,9 which will increase the policy priority afforded to this issue; and third, the potential, through effective tobacco control policy implementation, to prevent full escalation of the tobacco epidemic, particularly in Africa. As well as exploring tobacco industry market expansion tactics and policy influence generally, we examine three mechanisms through which tobacco companies are increasingly attempting to prevent progress in tobacco control—the use of international trade and investment agreements, litigation, and the illicit trade in tobacco. Tobacco companies are also exploiting the opportunities presented by harm reduction10, 11 and regulatory developments such as Better Regulation to enhance their influence,12, 13 but these currently have less resonance in LMICs and are not, therefore, covered in detail. Finally, we outline how these problems might be addressed and highlight that, despite the egregious examples of industry influence detailed, some LMICs are exemplars in tobacco control and show what can be achieved by prioritising health over tobacco industry interests.14
Key messages
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The tobacco industry's future depends on increasing tobacco use in low-income and middle-income countries, especially among women and young people, and, contrary to industry claims, tobacco marketing deliberately targets these groups
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Tobacco companies consistently contest and seek to circumvent governments' authority to implement public health measures using highly misleading arguments frequently presented via third parties whose links to industry are obscured
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Tobacco companies harness their resource advantages in, for example, establishing partnerships with governments to address the trade in illicit tobacco in which they have been complicit and using the threat of domestic litigation and arbitration under trade and investment agreements to intimidate governments against implementing comprehensive tobacco control measures
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Article 5.3 of the Framework Convention on Tobacco Control and its guidelines offer governments a set of strategies to protect public health against the tobacco industry's appalling conduct, but are underused
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An essential first step in addressing tobacco industry interference is changing attitudes to the industry through actively monitoring and exposing its conduct