MPOWER Brochure

Monitor
tobacco use
and prevention
policies
The WHO Framework Convention
on Tobacco Control states:
Article 20
The Parties shall establish …
surveillance of the magnitude,
patterns, determinants and
consequences of tobacco
consumption and exposure to
tobacco smoke.
… Parties should integrate
tobacco surveillance programmes
into national, regional and global
health surveillance programmes
so that data are comparable and
can be analysed at regional and
international levels …
Population-based national and international monitoring
data are necessary to effectively plan and implement
the WHO Framework Convention on Tobacco Control
(WHO FCTC).
Only through accurate measurement can problems caused
by tobacco be understood and interventions be effectively
managed and improved.
Monitoring can provide policy-makers and public health
authorities with essential information on:
●● The extent of the tobacco epidemic in a country
●● Subgroups in need of tailored policies and programmes
●● Public awareness of the epidemic and attitudes towards
tobacco control
●● Changes in tobacco use following implementation of
policies and programmes
●● Government enforcement and societal compliance with
tobacco control policies, including tax collection and
tax evasion, smoke-free places, and advertising and
marketing bans
●● Tobacco industry practices that may increase tobacco
use or hinder implementation of tobacco control policies
and programmes
Monitoring is also essential to evaluate the effectiveness of
MPOWER implementation. Currently, monitoring systems
are weak in many low- and middle-income countries, where
tobacco use is rising fastest.
Many countries do not
have monitoring data
All countries need effective tobacco surveillance systems.
However, many countries lack national smoking prevalence
data for adults and youth, or have older data or data that
are not representative.
Data on other aspects of the epidemic – such as tobacco-
related disease and death, the economic costs of tobacco
use, public attitudes towards tobacco control and the
extent of tobacco marketing – are also inadequate.
Assessment of tobacco use and its impact must be
strengthened, as monitoring at both global and country-by-
country levels is critical to understanding and contributing
to the information base necessary to reverse the tobacco
epidemic.
Monitoring must be
scientifically valid
Any monitoring system must use standardized and
scientifically valid data collection and analysis practices.
Surveys that use a random population-based sample of
sufficiently large size can provide accurate estimates of
tobacco use at the national level within an acceptable
margin of error. Moreover, surveying a sufficiently large
sample enables accurate estimates of smoking prevalence
among major subpopulations – classified by age, gender,
income, region and other sociodemographic characteristics.
Surveys should be implemented at regular intervals to
ensure that changes in the epidemic are measured.
Monitor Monitor tobacco use and
prevention policies
Protect Protect people from
tobacco smoke
Offer Offer help to quit tobacco use
Warn Warn about the
dangers of tobacco
Enforce Enforce bans on tobacco
advertising, promotion and
sponsorship
Raise Raise taxes on tobacco
The WHO Framework Convention on Tobacco Control (WHO
FCTC) is the pre-eminent global tobacco control instrument,
which contains legally binding obligations for its Parties
and provides a comprehensive direction for tobacco control
policy at all levels. WHO introduced the MPOWER package
of measures to assist in the country-level implementation
of effective measures to reduce the demand for tobacco,
contained in the WHO FCTC.
Additional resources on this topic are available at
www.who.int/tobacco/mpower/publications
2500
2000
1500
1000
500
0
Numberofpeopleinmillions
5% 6%
8% 8%
9%
ProtectMonitor Offer Warn Enforce Raise
34%
Percentage OF GLOBAL POPULATION COVERED BY , 2008
Monitoring is a
critical tobacco control activity
Technical input and assistance in publication was provided
by The International Union Against Tuberculosis and
Lung Disease (The Union) with funding from Bloomberg
Philanthropies and support from World Lung Foundation. Data from 2008. Source:WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva,World Health Organization, 2009.

Monitor tobacco use
and prevention policies
Conducting
effective surveys
Surveys can be conducted on tobacco use alone, or can be
combined with surveys on other health issues of interest to
a country’s government.
Standardized questions about tobacco use
prevalence and implementation of MPOWER
measures to reduce tobacco use can be
embedded in existing population-based
surveys or censuses.
Surveys should be repeated at regular intervals, using the
same survey questions and sampling and data analysis
techniques. This enables data from different surveys to be
comparable, allowing accurate evaluation of the impact of
interventions over time.
Partners can
assist with surveys
Statistically valid surveys can be expensive to conduct.
Costs rise further if large populations are surveyed on a
number of different measures.
Survey partners with sufficient technical capacity – such as
national statistics offices, universities and private research
firms – can be enlisted. These partners can support
monitoring activities, including survey administration and
data collection, management and analysis.
Consistent
data collection
Standardized questions and surveillance measures are vital.
It is important to coordinate with tobacco control partners
to ensure the development of consistent surveys.
Key indicators are included in the Global Adult Tobacco Survey
(GATS), a nationally representative household survey, which
feeds into the Global Tobacco Surveillance System.
The Global Youth Tobacco Survey (GYTS) is a school-based
survey of students aged 13–15 years that also informs the
Global Tobacco Surveillance System.
There are two key questions when surveying prevalence of
tobacco use:
●● What types of tobacco are used?
●● How many people use tobacco?
Key indicators for monitoring the baseline and impact of
tobacco control policies include:
●● Exposure to second-hand smoke in public places, at
work and at home
●● Price paid for tobacco and purchase location
●● Exposure to tobacco advertising
●● Exposure to tobacco pack warning labels and anti-
tobacco counter advertising
●● Beliefs about the health harms of tobacco
●● Physician advice to quit and cessation attempts
The proportion of former smokers (people who have ever
smoked regularly and have quit) is a useful indicator of
progress in tobacco control.
Studies for effective
tobacco control
For the effective development and implementation of
tobacco control policies and to increase stakeholder
support, a range of localized studies may also prove useful.
These could include:
●● Assessments of government enforcement of tobacco
control policies, and tobacco industry and societal
compliance with them
●● Polls to measure public acceptance of tobacco control
initiatives and perceived levels of compliance with policies
●● Epidemiologic studies to determine the burden of
tobacco-related illness and death and the impact of
tobacco control interventions on health
Economic research can provide important information on
both tobacco use and the impact of tobacco control policy.
Examples include:
●● Studies to determine the economic impact of particular
tobacco control policies, including gains associated with
reductions in tobacco-related death and ill-health
●● Estimates of per capita consumption of tobacco, based
on sales, tax, manufacturing, import and export data
●● Studies to determine the economic costs of smoking and
second-hand smoke, from direct medical expenses as
well as productivity losses
●● Calculation of revenues generated by tobacco excise
taxes and disbursements for tobacco control programs
Monitoring the tobacco industry is important for effective
adaptation of tobacco control policy. Key issues include:
●● The extent and type of tobacco advertising, marketing
and promotional activities – including tobacco industry
sponsorship of public and private events
●● Tobacco industry interference with the development and
implementation of effective tobacco control measures
National and global
collaboration is needed
To maintain an effective monitoring system, collaboration
is needed – within countries and internationally – among
health practitioners, economists, epidemiologists, data
managers, government officials and many others.
GATS can guide efforts to collect
internationally comparable data.
GATS surveys use common sampling procedures, core
questionnaires and data management across countries.
Publicize findings
Data that highlight the burden of tobacco use, as well as
the status and effectiveness of tobacco control policy
implementation, should be emphasized.
Data from monitoring can become
critical evidence to promote stronger
policies.
Findings should be disseminated through government
policy papers, academic publications and mass media
(news reports, as well as paid media).
Broad dissemination of survey findings allows governments,
country leadership and civil society to use them to develop
tobacco control policies. This also helps build capacity
for effective policy development, implementation and
enforcement.
Pretesting the GATS questionnaire in Indore, Madhya Pradesh, India.
©KrishnaPalipudi/CDC/2008
Collecting Global Adult Tobacco Survey data
from a fisherman in south-western Bangladesh.
©DrXiaQinghua/2009
Conducting the GATS
in Wuhan, Hubei Province, China.
©NuttaponTheskayan/MinistryofHealthThailand/2009
Analysing GYTS data in Brazzaville, Congo.
©NathanJones/CDC/2008

Protect people
from tobacco
smoke
Article 8
… scientific evidence has
unequivocally established that
exposure to tobacco smoke
causes death, disease and
disability.
Each party shall adopt and
implement … measures,
providing for protection from
exposure to tobacco smoke
in indoor workplaces, public
transport, indoor public places
and, as appropriate, other public
places.
Second-hand smoke
exposure is deadly
There is no safe level of exposure to tobacco smoke.
Exposure to tobacco smoke is proven to cause heart
disease, cancer and many other diseases.
Just 30 minutes of exposure to tobacco smoke changes
the way in which blood flows and clots, increasing the
risk of heart attack and stroke. Second-hand smoke kills
more than 600,000 people each year. In many countries, it
causes more than 10% of all tobacco-related deaths.
Only 100% smoke-free
environments protect
health
All people have a fundamental right to breathe clean air.
Completely smoke-free indoor environments – with no
exceptions – are the only proven way to protect people.
100% smoke-free environments require the elimination of
all smoking and tobacco smoke indoors. Ventilation cannot
protect against the health risks of tobacco smoke.
Do not allow exemptions
Protection from tobacco smoke should be universal: all
people deserve health protection, all the time.
Exceptions to 100% smoke-free indoor
environments – such as permitting smoking
in designated areas or installing ventilation
systems – do not protect health.
The tobacco industry has acknowledged the effectiveness
of smoke-free environments. Their data show that
exceptions to 100% smoke-free environments undermine
the impact of such regulations.
Smoke-free laws
are popular
Experience consistently shows that smoke-free laws are
practical, popular – even among smokers – and successful,
despite industry claims to the contrary.
prevention policies
tobacco smoke
Warn Warn about the
dangers of tobacco
sponsorship
In 2008, 114 countries lacked or had
minimal smoke-free legislative protection
Smoke-free laws
do not hurt business
A review of the economic effects of smoke-free environments
around the world concludes that they do not have a negative
economic impact on businesses. In many cases, smoke-free
laws have even had a slight positive economic impact.
Economic impact studies of smoke-free laws have shown
no adverse effect on bar and restaurant businesses or
tourism. Evidence of this type can be used to counter false
tobacco industry claims.
Smoke-free laws
protect worker health
The primary purpose of establishing smoke-free workplaces
is to protect workers’ health.
Framing the debate about smoke-free workplaces as a
worker safety issue can help build support.
The International Covenant on Economic, Social and
Cultural Rights recognizes the right of all people to safe
and healthy working conditions. Workers have the right to
earn a living without endangering their health by breathing
second-hand smoke.
Clean air – a basic human right
Not categorized
Up to two categories of
public place (health-care,
educational and government
facilities, universities, indoor
ofﬁces, restaurants, pubs,
bars and public transport)
completely smoke-free
Three to ﬁve categories of
public place completely
smoke-free
Six to seven categories of
public place completely
smoke-free
All public places completely
smoke-free (or at least 90%
of the population covered by
complete subnational
smoke-free legislation)
High-incomeMiddle-incomeLow-income
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Proportion of countries (Number of countries inside bars)
23
14
3
5
3
60
20
10
1
6
31
12
2
3
1
Philanthropies and support from World Lung Foundation.
Data from 2008. Source:WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva,World Health Organization, 2009.

Protect people from
tobacco smoke
Smoke-free laws
help smokers quit
Smoke-free environments help smokers who want to quit.
Cigarette consumption in the United States is between 5%
and 20% lower per capita in states with comprehensive
smoke-free laws.
In a review of smoke-free workplaces, the average
consumption of cigarettes fell by 3.1 cigarettes per day per
smoker compared to workplaces that were not smoke-free.
Protect children,
the sick and all workers
Smoke-free regulations can be easily enacted in facilities
under direct government control or regulation.
It is relatively easy to gain support for
protecting children and the sick through
smoke-free schools and health-care facilities.
However, the vast majority of people in most countries are
employed by the private sector. It is therefore important
to make all indoor workplaces smoke-free to protect the
largest number of people.
Make restaurants
and bars smoke-free
Restaurants, bars and other hospitality venues are
also workplaces and should be covered by smoke-free
workplace policies.
It is important to counter the perception that smoking is
integral to restaurants, bars and other hospitality venues.
Public opinion polls showing strong support for making
restaurants and bars 100% smoke-free are important in
securing support for legislation among businesses and
policy makers.
Smoke-free laws lead
to smoke-free homes
For children and adults who do not work elsewhere, most
exposure to second-hand smoke takes place at home.
Establishing smoke-free public places encourages families to
make their homes smoke-free. This protects children and other
family members from the dangers of second-hand smoke.
Teenagers who live in homes where
smoking is allowed are nearly twice as
likely to start smoking than those in
homes where smoking is prohibited.
Smoke-free laws
change social norms
Smoke-free environments contribute to changing the social
norm to make smoking less acceptable. This helps to further
reduce both smoking and exposure to tobacco smoke.
Counter tobacco
industry myths
The tobacco industry and its allies have tried to stop, delay
and weaken 100% smoke-free policies by interfering and
misinforming at different stages of smoke-free development
and implementation.
Myths, such as the threat of economic loss, continue
to be spread by the tobacco industry. These myths and
opposition can be anticipated and countered.
Any country can
implement smoke-free
laws
Experience in a growing number of countries and sub-
national areas shows it is possible to enact and enforce
effective smoking bans, and that doing so:
●● is popular with the public
●● improves health
●● does not harm businesses
Too often, smoke-free laws cover only some indoor spaces,
are weakly written or are poorly enforced.
Gain support for
smoke-free laws
Public support is critical to the success of smoke-free laws.
Support can be gained through effective education about
the harms of second-hand smoke exposure and a clear
explanation of the purpose of the law.
Health-care professionals and non-governmental
organizations involved with health, education, child
protection, women’s issues and human rights are important
allies in gaining support from both the public and political
leaders. Support of trade unions and other worker groups is
critical to implementing workplace smoking bans.
Effective smoke-free
legislation
Smoke-free legislation should be clearly written and
comprehensive. There should be no exemptions and there
should be clear responsibility for enforcement.
The law should clearly define the act of smoking, specify
all indoor areas covered, and mandate posting of clear and
conspicuous signage.
The government agency responsible for enforcement should
be clearly defined, as should penalties for violations.
Enforcement is
necessary
Once enacted, laws establishing smoke-free places must be
well enforced.
Administrators, managers or proprietors,
rather than individual smokers, should
bear primary responsibility for ensuring
enforcement.
Although maintenance of smoke-free places is largely self-
enforced in the long-term, it may be necessary to increase
the level of enforcement immediately after smoke-free laws
are enacted.
Once there is a high level of compliance, it is usually
possible to reduce enforcement measures, with regular
monitoring.
A road sign welcome visitors to Chandigarh, India, a smoke-free city.
©DrHonneySawhney/2009
A no-smoking sign erected under city-wide
smoke-free laws in Mexico City.
©JonathanRomo/TheUnion/2009
Signage from smoke-free Chao-Yang Hospital, Beijing, China.
©DrWangJing/2009
Campaigning for smoke-free public transport in Bangladesh.
©WBBTrustBangladesh/2008
Anycountry,regardlessofincomelevel,can
develop and introduce smoke-free laws
effectivelybyfollowingtheArticle8Guidelines
for implementation of the WHO FCTC.

Offer help to
quit tobacco use
Article 14
Each Party ... shall take
effective measures to promote
cessation of tobacco use and
adequate treatment for tobacco
dependence.
Each Party shall endeavour to
design and implement effective
programmes aimed at promoting
the cessation of tobacco use
[and to] include diagnosis and
treatment of tobacco dependence
and counselling services on
cessation of tobacco use in
national health and education
programmes, plans and
strategies ...
More than one billion smokers worldwide – a quarter of all
adults – are victims of the tobacco epidemic. Like people
dependent on any addictive drug, it is difficult for tobacco
users to quit. However, most people want to quit when
informed of the health risks.
Tobacco control policies create the environment in
which users can successfully stop. Cessation support and
medication can increase the likelihood that a smoker will quit
successfully. However, few smokers currently receive the help
and support they need to overcome their dependence.
Health-care systems
are responsible for
treatment
Tobacco dependence treatment is primarily the responsibility
of each country’s health-care system.
Countries should establish programmes that provide low-
cost, effective interventions for tobacco users to stop.
Cost analyses have shown the benefits from tobacco
cessation programmes to be either cost-saving or cost-neutral.
Yet, few smokers currently receive the help and support
they need to overcome their dependence.
Three primary forms of
treatment
Treatment includes various methods, but programmes
should include:
●● Tobacco cessation advice incorporated into primary and
routine health-care services
●● Easily accessible and free telephone help lines (known
as quit lines)
●● Access to free or low-cost cessation medicines
These methods work best when adapted to local conditions
and cultures, and tailored to individual preferences and needs.
Quit advice from all
health professionals is
effective
Clear, strong, personalized advice from all health professionals
about the risks of tobacco use and the importance of quitting
is usually well-received and increases quit rates.
Brief advice (1-3 minutes) is inexpensive when integrated
into existing health-care services.
Health-care systems should encourage
all health professionals to routinely ask
all patients about their tobacco use and
provide advice to stop.
All health-care workers must be motivated to provide
advice.
prevention policies
tobacco smoke
Warn Warn about the
dangers of tobacco
sponsorship
Few smokers get the help they need
Cessation services and
cessation support
All health professionals should offer cessation support to
smokers, or refer smokers to a cessation service where
possible.
Cessation support includes:
●● Promoting the benefits of cessation
●● Assessing the degree of nicotine dependence
●● Assisting smokers in setting a quit date
●● Advising that complete abstinence from smoking is best
●● Arranging effective medication, if available
●● Arranging follow-up
All health-care workers should be trained in giving brief
advice to quit and offering cessation support to tobacco
users.Technical input and assistance in publication was provided
In 2008, smokers in 98 countries had to pay for any
tobacco dependence treatment. In 23 countries no
treatment was available
High-income
Middle-income
Low-income
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Proportion of countries (Number of countries inside bars)
1516 113 3
8554 30
14287
National quit line, and some
cessation services and
nicotine replacement therapy
(NRT) cost covered.
Some cessation services
and/or NRT, at least one of
which is cost-covered.
Some cessation services
and/or NRT, neither cost
covered.
None
Data not reported
Data from 2008. Source:WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva,World Health Organization, 2009.

Offer help to quit
tobacco use
Health professionals
should not smoke
Doctors and other health-care workers are most effective
in assisting patients to quit when they serve as role models
by not smoking themselves. Their effectiveness increases
further if they are visibly involved in local and national
tobacco control activities.
In some countries, a high proportion of physicians smoke –
particularly male physicians. In addition to setting a deadly
example for their patients, doctors who smoke undermine
tobacco control messages and policies.
Quit lines are effective
Advice and counselling can also be provided in the form of
telephone quit lines. These should:
●● Be free of charge
●● Provide information similar to that available from
in-person counselling
●● Be staffed by live operators, rather than use pre-
recorded messages
●● Be accessible to the public at convenient times
Where feasible, additional cessation materials and links to
more intensive counselling should be provided.
Quit lines are most useful in countries where telephone
service is universal and the public is accustomed to making
phone calls for services.
Quit lines require financing and training of staff to answer
incoming calls and provide appropriate counselling or
referral for services.
Quit line follow-up is
important
Quit lines are most effective when staff take proactive
measures to make follow-up phone calls to check on
progress and provide encouragement to:
●● Quit
●● Maintain abstinence
●● Make another quit attempt in case of relapse
Multiple follow-up calls at regular intervals have the
greatest likelihood of keeping people committed to long-
term cessation.
Emerging communications technologies such as text
messaging and social networking web sites can also be
effective.
Cessation medications
are effective
Cessation medications can double or triple the likelihood of
successfully quitting.
The highest quit rates are achieved
when cessation support is
combined with medication.
Medication is also effective when provided separately.
Prescription medications should be provided through
the health-care system. At least some form of nicotine
replacement therapy (NRT) should be available over-the-
counter without prescription at retail pharmacies.
There are two main types of cessation medication available:
●● NRT (patches, lozenges, gum, oral inhalers and nasal
spray).
●● Prescription-only medicines such as bupropion and
varenicline. These are intended for short-term therapy.
Two forms of NRT are included on the
WHO Model List of Essential Medicines.
Cessation programmes
are politically feasible
Cessation programmes generally encounter few political
obstacles. They help foster support for policies to reduce tobacco
use, an important step in creating a tobacco-free society.
Cessation programmes enable governments to help those
most directly affected by the epidemic at the same time as
they enact new restrictions on tobacco.
Most countries can use lower-cost counselling options
effectively, even if funds for medications are limited.
This may also reduce opposition to other tobacco control policies.
Governments can use tobacco tax
revenues – ultimately collected from
smokers themselves – to subsidize
cessation services.
Cessation services are
cost-effective
Clinical cessation services are much more cost-effective
than most other health-care system activities. They are most
effective when combined with other MPOWER measures.
While cessation services have a smaller population impact
than other MPOWER interventions (such as tax increases,
bans on advertising, promotion and sponsorship, anti-
tobacco advertising and establishment of smoke-free
places), they have a great impact on individual health.
The risks of developing a tobacco-related illness are significantly
reduced within a few years among those who quit smoking
before they develop such an illness, regardless of their age.
Quit line details on a cigarette packet, Australia.
©jswhitley.com/TheUnion/2010
Measuring lung function on World No Tobacco Day
in Mexico City to encourage cessation.
©JonathanRomo/TheUnion/2009
Nicotine gum.
©NickGarrad/2008
Cessation advice area at a hospital in Beijing, China.
©DrXiaoDan/2009

Warn about
the dangers of
tobacco
Article 11
Each Party shall … ensure that
tobacco product packaging
and labelling do not promote a
tobacco product by any means
that are false, misleading [or]
deceptive …
Each Party shall … ensure that…
tobacco products … carry health
warnings describing the harmful
effects of tobacco use …
Article 12
Each Party shall promote and
strengthen public awareness of
tobacco control issues, using all
available communication tools …
Despite conclusive evidence on the dangers of tobacco, few
tobacco users worldwide understand the full extent of the
health risks.
Many smokers believe that they can reduce or stop tobacco
use before health problems occur.
Both smokers and non-smokers underestimate the
addictiveness of tobacco and the risk it poses to health.
Both smokers and non-smokers also underestimate the
danger of exposure to second-hand tobacco smoke. These
threats have not been adequately explained to the public.
The need for public education is even more pronounced in
low- and middle-income countries, where tobacco use is on
the rise and tobacco control is generally in its early stages.
Effective warning labels, anti-tobacco advertising and the
proactive use of media to influence the public and policy-
makers are three key ways to communicate the health risks
of tobacco .
Warning labels increase
awareness of health risks
Prominent warning labels on tobacco packs are the most
direct way of communicating health risks to tobacco users.
Effective health warnings on cigarette packs encourage
smokers to quit and discourage non-smokers from starting.
Best practice warning labels, that comply
with the Guidelines for implementing
Article 11 of the WHO Framework
Convention on Tobacco Control (WHO
FCTC), reach all tobacco users, increase
their awareness of health risks, are
well-accepted by the public and cost
governments virtually nothing.
Warnings change the
image of tobacco
Comprehensive warnings about the dangers of tobacco are
critical to changing its image, especially among adolescents
and young adults.
People need to associate tobacco use with its actual human
impact, extreme addictiveness and dangerous health
consequences, and to see it as socially undesirable and
negative.
Health warnings and anti-tobacco
advertising encourage tobacco users to
quit and help keep young people from
starting.
Warnings and anti-tobacco advertising also help gain public
acceptance of other tobacco control measures such as
establishing smoke-free environments.
prevention policies
tobacco smoke
Warn Warn about the
dangers of tobacco
sponsorship
56% changed their opinion
about health consequences
of smoking
67% want to quit
as a result
54%
67%
0%
20%
40%
60%
80%
Source: Datafolha Instituto de Pesquisas. Opinião pública, 2002.
Impact of pictorial warnings on Brazilian smokers
Smokers approve of pictorial warnings
76% approve
of health warnings
73%
Few smokers and non-smokers
fully understand the health risks of tobacco
Warning labels on tobacco packaging and hard-hitting mass media campaigns provide crucial
information about the dangers of tobacco use.

Warn about the
dangers of tobacco
Characteristics of
effective warning labels
Best practice health warning labels should:
●● Describe the harmful effect of tobacco use
●● Be large, clear, visible, and legible, covering 50% or
more of principal pack display areas (both front and
back) and in no case less than 30%
●● Rotate periodically so that they continue to attract the
attention of the public
●● Appear in the country’s principal language(s)
●● Include graphic pictures
●● Be approved by the competent national authority
Misleading descriptors
Studies show that more than half of smokers incorrectly
believe that the terms “light” and “ultra-light” refer to
cigarettes that are less harmful to their health. Misleading
descriptors – such as ‘low tar’, ‘light’, and ‘mild’ – and any
packaging that creates a false impression of the product
being less harmful should be banned.
Tobacco packaging that creates a false
impression of the product being less
harmful than other forms of tobacco
should be banned.
Tobacco packaging should contain information on relevant
constituents and emissions of tobacco products. However,
statements about tobacco constituents and emissions must
not imply that a product is less harmful than other tobacco
products.
Maximizing the impact
of warning labels
There are several ways to maximize the effectiveness of
warning labels:
●● Use pictures with graphic, culturally appropriate
depictions of disease and other negative images in full
color. Pictures have more impact on most smokers than
words alone. They are also critical in reaching the large
number of people worldwide who cannot read.
●● Elicit unfavorable emotional associations with
tobacco use by addressing harmful health effects,
addiction potential and adverse social and economic
consequences.
●● Use strong and clear language that describes specific
diseases caused by tobacco use and exposure to second-
hand smoke.
●● Other required packaging, labelling or markings should
not obstruct warning labels.
●● Measures mandating plain and generic packaging that
prohibits the use of logos, brand images, or promotional
information should be considered.
In Singapore, where highly graphic warnings are used, 71%
of smokers said they knew more about the health effects of
smoking because of warning labels.
Anti-tobacco advertising
increases awareness of
health risks
Anti-tobacco advertising in all forms of media can help
publicize the full extent of tobacco’s dangers.
When exposed to graphic anti-tobacco messages on
television, smokers are more likely to quit.
Campaigns using graphic images that
demonstrate the physical harm caused
by tobacco use are especially effective in
convincing users to quit.
High-quality
advertising is feasible
Sustained, highly visible and effective counter-advertising
campaigns can be expensive. However, advertising can be
easily and inexpensively adapted from content that has
been used successfully in other countries.
Obtaining free or low-cost television and radio time
can also reduce costs. In Turkey, all television and radio
channels are required to devote 90 minutes of free airtime
each month to tobacco control and addiction, including
30 minutes of prime time. Remaining costs can be covered
through tobacco tax or other government revenues.
Professional companies, including advertising agencies,
should be used to develop creative materials, especially
for television. Anti-tobacco advertising should have the
same production quality and persuasive power as tobacco
industry propaganda.
Advertising should be systematically tested with focus
groups before being run to ensure that anti-tobacco
messaging has the intended effect.
“Earned media”
is effective and
inexpensive
Public relations activities can further educate people
about the harms of tobacco and counter tobacco industry
misinformation. As such, anti-tobacco educational
campaigns should include efforts to obtain news coverage
by working with journalists to develop stories or writing
letters to the editor.
This is sometimes referred to as “earned media” because,
unlike advertising, no space or air time is purchased, so
costs are relatively low.
Public relations efforts should be
proactive and engage the media
whenever there are developments in
tobacco control.
The media will usually cover the following events as news:
●● Introduction or passage of new laws in agreement with
the WHO FCTC
●● Implementation of MPOWER measures such as smoke-
free places, anti-tobacco advertising and pack warnings
●● Launch of an anti-tobacco advertising campaign
●● Release of new research findings
Advocates need to make sure factual tobacco control
messages are included in any related press.
The media can also be encouraged, to reveal industry
marketing and lobbying tactics, cover the health and
economic harms of tobacco, highlight the progress of
tobacco control in local communities or feature anti-
tobacco outreach activities conducted by youths.
Local stories with strong human interest angles and backed
with facts are likely to gain the greatest attention from
media and their audiences.
A TV advertisement in China warns about the
dangers of smoking and discourages giving cigarettes as gifts.
©WorldLungFoundation/2010
One of ten graphic pack warnings required in Brazil.
©MinistryofHealthBrazil/2008
‘Cigarettes cause lung cancer’: one of nine pack warnings, Thailand.
©ASHThailand/2006
Anti-tobacco advertising about the health harms
of secondhand smoke, Sao Paulo, Brazil.
©WorldLungFoundation/2010

Enforce bans
on tobacco
advertising,
promotion and
sponsorship
Article 13
… a comprehensive ban on
sponsorship would reduce the
consumption of tobacco products.
Each Party shall … undertake a
comprehensive ban of all tobacco
sponsorship.
The tobacco industry spends tens of billions of US dollars
worldwide each year on marketing through advertising,
promotion and sponsorship.
Advertising, promotion and sponsorship normalize tobacco,
making it seem like any other consumer product. This
increases its social acceptability and hampers efforts to
educate people about the hazards of tobacco use.
Marketing falsely associates tobacco with desirable
qualities such as energy, glamour and sex appeal. It also
strengthens the tobacco industry’s influence over media,
sporting and entertainment businesses.
In countries where partial bans prohibit direct advertising
and promotion of tobacco products in traditional media,
tobacco companies frequently employ indirect marketing
tactics to circumvent the restrictions. Tactics include:
●● sport and music event sponsorship
●● pack designs and displays
●● branded merchandise
●● product placement
●● alleged corporate-social responsibility activities
●● new media technology campaigns
Advertising, promotion
and sponsorship bans
work
Comprehensive bans on direct and indirect advertising,
promotion and sponsorship protect people – particularly
youth – from industry marketing tactics and can
substantially reduce tobacco consumption.
Comprehensive bans significantly reduce the industry’s
ability to market to young people who have not started
using tobacco and to adult tobacco users who want to quit.
Comprehensive bans can be achieved by
following the international best practice
standards outlined in the Guidelines
for implementation of Article 13 of the
WHO Framework Convention on Tobacco
Control (WHO FCTC).
A comprehensive ban on all advertising and promotion
reduces tobacco consumption by about 7%, independent of
other interventions. Some countries have seen consumption
drop by as much as 16%.
Bans must be
comprehensive
To be effective, bans must be
comprehensive and apply to all
types of advertising, promotion and
sponsorship – both direct and indirect.
Bans on direct advertising should cover all types of media
– including print, broadcast, billboards and other outdoor
advertising (such as on transit vehicles and stations), and
the internet.
Legislation should include bans on in-coming and out-going
cross-border advertising, such as tobacco advertising on
international television and Internet sites, and sponsorship
of international sporting and cultural events.
Bans should also cover promotional strategies such as price
discounts and free product giveaways.
Ban point of sale
advertising and
promotion
Point of sale promotion – including price discounts and
product giveaways – can account for more than 75% of
tobacco company marketing expenditure.
Point of sale advertising and in-store displays of tobacco
products should be banned. Bans on product display lead
to reductions in youth smoking and also reduce impulse
purchases among adults wanting to quit.
Keeping tobacco behind the counter and out of public
view can be effective. Even the extra effort required to ask
a retailer for tobacco products is often enough to deter
purchasers.
Certain countries are beginning to require generic
packaging of tobacco products. Requiring plain or generic
packaging – without colour, pictures or distinctive
typefaces, other than health warnings – can neutralize the
value of individual brands.
prevention policies
tobacco smoke
Warn Warn about the
dangers of tobacco
sponsorship
Enforce bans on tobacco advertising, promotion and sponsorship - best practice countries, 2008
Enforce bans on tobacco advertising, promotion and
sponsorship – HIGHEST ACHIEVING countries, 2008
The tobacco industry spends billions to market its deadly products
Philanthropies and support from World Lung Foundation. Source:WHO Report on the Global Tobacco Epidemic, 2009. Implementing smoke-free environments. Geneva,World Health Organization, 2009.

Enforce bans on
tobacco advertising,
promotion and
sponsorship
Ban all forms of
indirect advertising
and promotion
All forms of indirect tobacco advertising promotion and
sponsorship should be banned, including:
●● Sponsorship of music, cultural and sporting events
●● Use of non-tobacco products to promote tobacco brands
or companies
●● Endorsement by celebrities
Measures should also be put in place to severely restrict
tobacco imagery in entertainment media such as films and
television.
Tobacco companies invest in sophisticated branding to
promote their products. In many low- and middle-income
countries, more than a third of young people own an object
with a cigarette brand logo. Prohibiting the use of tobacco
branding on clothing and other items can counter this
powerful technique.
It is also important to prohibit free giveaways of tobacco
and related products.
Tobacco companies frequently engage in activities that
they categorize as ‘corporate social responsibility’ (CSR),
including sponsorship of research, charities and community
projects. CSR is intended to improve the image of tobacco
companies as socially acceptable economic contributors
and persuade governments not to implement policies that
may reduce tobacco sales. Bans on this form of promotional
activity are another important part of comprehensive
tobacco control.
Partial bans do not work
Partial bans have little or no effect
because the industry simply diverts
resources to other types of advertising,
promotion and sponsorship.
For example, if only broadcast advertising is banned, other
types of marketing (such as newspaper and magazine,
billboard, point of sale and Internet) will proliferate.
If direct advertising is banned, sponsorship of events
popular among young people – such as racing, sports and
music festivals – may expand. Often, partial bans fail to
include all indirect or alternative forms of promotion.
Implementing
effective bans
Policy-makers should announce bans on advertising,
promotion and sponsorship well in advance of
implementation. This provides sufficient time for media and
other businesses to find new advertisers and sponsors.
Comprehensive bans on advertising,
promotion and sponsorship
must be periodically updated to take
account of innovations in industry tactics
and media technology.
Legislation should not include exhaustive lists of prohibited
activities, so as to cover future developments in marketing
technology and tactics. Examples of prohibited advertising,
promotion and sponsorship are useful in legislation,
provided that it is clear that they are examples only.
Monitoring and
enforcement are key
Tobacco industry advertising, promotion and sponsorship
activities should be monitored to ensure compliance with
bans.
Monitoring should cover traditional media and marketing
channels, as well as novel and emerging marketing
strategies.
It is also important to include new technologies and
social trends, such as text messaging, chat groups and
underground nightclubs advertised through word-of-mouth,
in monitoring and enforcement programmes.
Strong legislation is
required
The industry often argues that outright bans on advertising,
promotion and sponsorship are not necessary and that
voluntary codes and self-regulation are sufficient. However,
voluntary agreements or codes do not work because they
are unenforceable. In addition, voluntary codes do not
cover tobacco retailers and consequently fail to prevent
point of sale advertising or displays, some of the most
common and insidious forms of marketing.
Governments should act to
ban tobacco advertising, promotion and
sponsorship through well-drafted and
well-enforced laws.
The industry is increasingly aggressive at circumventing
prohibitions on marketing activities that are designed to
reduce tobacco use.
Financial penalties should be substantial. The tobacco
industry is often willing to pay fines that are small in
comparison to the additional business gained by marketing.
Countering
industry opposition
The tobacco industry strongly opposes bans on advertising,
promotion and sponsorship because they are highly
effective in reducing tobacco use.
The industry also claims that bans restrict its right to free
speech, including the right to promote a legal product.
These claims can be countered:
●● Assert the right and duties of governments to protect
the health and rights of citizens.
●● Highlight the fact that many governments ban or restrict
advertising of other legal products, such as firearms and
medications, as part of consumer protection laws.
●● Emphasize the health and economic damage caused by
tobacco.
●● Call attention to the evidence that links tobacco
advertising, promotion and sponsorship to increased
overall consumption and uptake among youth.
People’s right to live free from harm
and addiction overrides the financial
interests of the tobacco industry.
Tobacco advertising in Malaysia.
©ACS/CTFK/FCA/2008
CSR: a counter-productive youth smoking prevention
campaign billboard in Columbia.
©ACS/CTFK/FCA/2008
Dance party sponsored by Surya cigarettes, Nepal.
©ACS/CTFK/FCA/2006
Point of sale marketing on cigarette packets
at a kiosk in Bangladesh.
©ACS/CTFK/FCA/2008

Raise taxes on
tobacco
Article 6
Price and tax measures are an
effective and important means of
reducing tobacco consumption …
Each Party should … adopt …
tax policies and … price policies
on tobacco products, so as
to contribute to the health
objectives aimed at reducing
tobacco consumption.
Article 15
Elimination of all forms
of illicit trade in tobacco
products, including smuggling,
illicit manufacturing and
counterfeiting … are essential
components of tobacco control.
Increasing the retail price of tobacco products through
higher taxes is the single most effective way to decrease
consumption and encourage tobacco users to quit.
When tobacco prices increase:
●● Fewer people use tobacco
●● People who continue to use tobacco, consume less
●● People who have quit are less likely to start again
●● The young are less likely to start using tobacco
Tobacco taxes are generally well accepted – and even
supported by many tobacco users – because most people
understand that tobacco is harmful.
In high-income countries, a 10% increase in tobacco prices
will reduce consumption by about 4%. The effect of higher
prices on reducing consumption is likely to be greater in
low- and middle-income countries.
Tobacco taxes protect
the poor and the young
Tobacco taxes are particularly effective in preventing
or reducing tobacco use among the young and the
poor. People in these groups are more affected by price
increases.
Tax increases help the poor to stop using tobacco. This
allows tobacco users who quit to reallocate their money
to essential goods, including food, shelter, education and
health-care.
Higher taxes also help poor families improve productivity
and wage-earning capacity by decreasing tobacco-related
illness and death.
Have a simple and
effective tax structure
There are two main types of tobacco excise taxes:
●● Specific taxes – levied on a given quantity of tobacco,
such as a tax paid per pack or carton of cigarettes
●● Ad valorem taxes – based on a percentage of the
wholesale or retail price
In some countries, a combination of excise taxes is used.
●● Specific taxes provide more predictable revenue and
make it harder for the tobacco industry to influence
retail prices.
●● Ad valorem taxes help tobacco prices maintain pace with
inflation.
The overall tax structure should be simple and easy for
countries to implement.
Excise taxes should be levied at the manufacturer level,
rather than at the distributor or retail level. This helps
increase effectiveness by centralizing revenue collections
and minimizing recordkeeping burdens on small businesses.
prevention policies
tobacco smoke
Warn Warn about the
dangers of tobacco
sponsorship
The WHO Framework Convention on Tobacco Control
(WHO FCTC) is the pre-eminent global tobacco control
instrument, which contains legally binding obligations
for its Parties and provides a comprehensive direction for
tobacco control policy at all levels. WHO introduced the
MPOWER package of measures to assist in the country-level
implementation of effective measures to reduce the demand
for tobacco, contained in the WHO FCTC.
When South Africa increased its taxes, smoking rates among the
poor and the young plummeted. Yet tax revenues increased.
When tobacco prices go up,
consumption goes down
Tobacco taxes reduce consumption
Relationship between cigarette consumption and excise tax rate in South Africa
Source: WHO Report on the Global Tobacco Epidemic, 2008.The MPOWER package. Geneva,World Health Organization, 2008.
2 500
2 000
1 500
1 000
500
0
Millionsofpacks
Excisetaxrate(asa%ofretailprice)
1980 1985 1990 1995 2000 2005
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Consumption (left scale)
Excise tax rate (right scale)

Increase taxes regularly
The goal of tobacco taxation is to reduce consumption by
making tobacco products progressively less affordable.
Governments should raise taxes
periodically so that real prices increase
faster than the combined effects of
inflation and increased consumer
purchasing power.
This is best accomplished by automatically linking tax
increases to economic indices. Otherwise tobacco becomes
relatively more affordable over time.
Seek expert advice
Different tobacco taxation schedules may raise the same
amount of revenue, but may either greatly reduce or have
little impact on consumption rates.
Expert consultation is important when establishing a
taxation system that has health goals – such as reducing
smoking – in addition to economic goals of raising revenue.
Economic experts can also provide evidence demonstrating
that higher taxes reduce tobacco consumption, increase
government ability to fund programmes and do not hurt
the poor.
Avoid product
substitution
If taxes increase the prices of more expensive products
without significantly increasing prices of cheaper ones,
many tobacco users will shift to less expensive brands
rather than reduce consumption.
Taxes should be increased on the most
commonly smoked and lowest-cost
products to prevent product substitution
with less expensive products.
Higher taxes do not
mean more smuggling
Contrary to tobacco industry claims, increased smuggling
does not automatically follow tax increases.
Tax evasion correlates more closely with poor governance
than it does with high levels of taxation.
A streamlined system under a single taxation authority that
focuses on manufacturers, with strong tax administration
and customs enforcement, facilitates compliance.
Stringent law enforcement costs only a small fraction of the
additional revenue earned from higher tobacco taxes.
Large financial penalties should be imposed for large-scale
tax evasion and smuggling operations.
Implement measures
to combat tax evasion
and smuggling
Tax evasion and smuggling can be reduced through:
●● Effective government record keeping
●● Improved border security and inspection procedures
●● Banking controls to reduce money laundering
●● Better communication among finance, customs
and other agencies involved in tax collection and
enforcement
Affixing tax stamps to every package
intended for retail sale and mandating
pack warnings in local languages further
reduce incentives for illicit trade.
Taxes can be levied on tobacco imports at the port of
entry as with any other customs duty. The same taxes
should be levied on imported cigarettes as on domestically
manufactured cigarettes. Duty-free sales of tobacco
products should be banned.
Use tobacco taxes to
pay for better health
A tax increase directly benefits governments through
increased revenues, at least in the short- and medium-term,
even when taking reduced consumption into account. In
most countries, tobacco tax revenues are thousands of
times higher than tobacco control expenditures.
To maximize the health impact of higher taxes, some
revenues should be earmarked for tobacco control and
other public health and social programmes. This makes
tobacco tax increases even more popular with the public,
including tobacco users.
It is also ethically appropriate for governments to use some
of the increased tobacco tax revenue to help tobacco users
quit through comprehensive tobacco control programmes.
Every country should
raise its tobacco taxes
In many countries, cigarette prices have not kept up with
increases in the price of other goods and services and
increased consumer purchasing power.
Every country can increase its tobacco
taxes to reduce smoking, raise funds for
tobacco control policies and pay for other
public health and social programmes.
Raise taxes on tobaccoTax stamps, Russia and Egypt (imported cigarettes).
©TheUnion/2009
Tax stamps, The Netherlands and Egypt (imported cigarettes).
©TheUnion/2009
Tax stamp, Russia.
©AlexanderKopylov/2009
Tax stamp, The Netherlands.
©CatalinaVoroneanu/TheUnion/2009

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