18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License REVIEW Tobacco control policies in the 21st century: achievements and open challenges  Lo Armando Peruga1,2,3 , Marıa Jose  pez4,5,6 , Cristina Martinez1,2,7,8 and ndez Esteve Ferna 1,2,7,8 1 Tobacco Control Research Group, Epidemiology and Public Health Research Programme, Institut d’Investigacio  Biomedica de Bellvitge-IDIBELL, Barcelona, Spain 2 Consortium of Centers for Biomedical Research on Respiratory Diseases (CIBERES), Madrid, Spain 3 Center for Epidemiology and Health Policies, Clınica Alemana School of Medicine, Universidad del Desarrollo, Santiago, Chile 4 Evaluation and Intervention Methods Service, Age ncia de Salut Pu blica de Barcelona, Spain 5 Consortium of Centers for Biomedical Research on Epidemiology and Public Health, CIBERESP, Madrid, Spain  Biome 6 Institut d’Investigacio dica de Sant Pau (IIB Sant Pau), Barcelona, Spain 7 Tobacco Control Unit, WHO Collaborating Center on Tobacco Control, Institut Catal a d’Oncologia-ICO, Barcelona, Spain 8 School of Medicine and Health Sciences, Campus of Bellvitge, Universitat de Barcelona, Spain Keywords Noncommunicable diseases (NCDs), including cancer, are responsible for cancer; global health; health policy; almost 70% of all deaths worldwide. Tobacco use is a risk factor common noncommunicable diseases; smoking; to most NCDs. This article discusses tobacco control policies and high- tobacco control lights major achievements and open challenges to reduce smoking preva- Correspondence lence and attributable morbidity and mortality in the 21st century. The E. Fernandez, Tobacco Control Unit, WHO introduction of the WHO Framework Convention on Tobacco Control in Collaborating Centre for Tobacco Control, 2005 has been a key achievement in the field and has already facilitated a Institut Catal a d’Oncologia-ICO, L’Hospitalet drop in both smoking prevalence and exposure to secondhand smoke. de Llobregat, Barcelona 08908, Spain Indicatively, the size of the worldwide population benefiting from at least E-mail: efernandez@iconcologia.net one cost-effective tobacco control policy has quadrupled since 2007. In addition, plain cigarette packaging has been successfully introduced as a (Received 16 November 2020, revised 11 January 2021, accepted 12 January 2021, tobacco control policy, surmounting efforts of the tobacco industry to available online 15 February 2021) challenge this based on trade and investment law. Nevertheless, tobacco control still faces major challenges. Smoking prevalence needs to be further doi:10.1002/1878-0261.12918 reduced in a rather expedited manner. Smoke-free environments should be extended, and the use of plain tobacco packaging with large pictorial health warnings for all tobacco products should be further promoted in some parts of the world. Some of these measures will require prompt deter- mination and diligence. For example, bold political decisions are needed to significantly increase real prices of tobacco products through excise taxes, ban added ingredients that are currently used to increase the attractiveness of tobacco products and ban the tobacco industry’s corporate social responsibility initiatives. Finally, the debate on harm reduction strategies for tobacco control still needs to be resolved. Abbreviations COVID-19, Corona virus disease 2019; CSR, Corporate Social Responsibility; FCTC, Framework Convention for Tobacco Control; ITP, Illicit Trade Protocol; MPOWER, Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; and Raise taxes on tobacco; NCD, noncommunicable disease; SDG, Sustainable Development Goal; WHO, World Health Organization; WTO, World Trade Organization. 744 Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License A. Peruga et al. Tobacco control achievements and challenges 1. Introduction 2. Achievements of tobacco control efforts during the first 20 years of the The 1964 US Surgeon General’s Report [1] and numer- 21st century ous other reports have established the terrible conse- quences of smoking on the health of smokers and 2.1. Galvanizing global political will around nonsmokers. At the end of the 20th century, tobacco international law had caused 100 million deaths worldwide, becoming a leading cause of totally preventable premature deaths. It The WHO FCTC entered into force in 2005 as bind- has been predicted that without any additional tobacco ing law for all treaty parties. As of January 2021, the control efforts, one billion people could die from causes treaty was adopted by 181 WHO member states and related to tobacco by the end of the 21st century, such the European Union, thereby covering more than as cancer, heart disease, stroke, lung diseases, diabetes, 90% of the world’s population. The Protocol to and chronic obstructive pulmonary disease [2]. Eliminate Illicit Trade in Tobacco Products, also An extremely profitable industry fueled the tobacco known as Illicit Trade Protocol (ITP), was introduced epidemic by selling a highly addictive product taking under the WHO FCTC in 2018. As of January 2021, advantage of globalization in the second half of the 62 WHO FCTC parties had also become parties to 20th century. Governments and public health organi- the protocol. zations became aware of the globalization and the sev- Galvanizing the global political will for implement- ere consequences of the tobacco epidemic and its ing the WHO FCTC and the ITP has been a key suc- evolution into a large-scale pandemic [3]. The signifi- cess in tobacco control. These treaties redefine the role cant economic toll of tobacco, which today amounts of international law in preventing disease and promot- to US$1436 billion, or 1.8% of the world’s annual ing health. Both treaties seek to establish cooperation gross domestic product [4], was soon realized. At the among countries to tackle, for example, cross-border same time, governments and public health organiza- advertising and illicit trade. Importantly, they seek to tions recognized that the pandemic needed a global establish international cooperation on matters that and coordinated high-level response. would otherwise be subject to national regulation In 1999, WHO initiated the proceedings to create because the sovereignty of nations to protect public the Framework Convention for Tobacco Control health is often challenged by the interests of the pow- (FCTC), the first international treaty under WHO aus- erful transnational tobacco industry. The tobacco com- pices. Followingly, the global community recognized panies often seek to expand the tobacco market tobacco use as a severe threat to global health, as well through various tactics, including intensive targeting of as a social and economic problem, and began to take women, children, and the poorer parts of society [5]. joint international action. This work highlights Therefore, the WHO FCTC and the ITP have solidi- achievements in tobacco control in the 21st century fied global governance of health matters and the foun- and discusses open challenges (Fig. 1). dation for countries to enact comprehensive, effective Fig. 1. Tremendous, although insufficient, progress has been made on tobacco control during the past 20 years. Nevertheless, there are still open challenges, and several measures remain to be implemented soon: increasing tobacco taxes, banning the use of additives, implementing plain packaging, banning tobacco industry’s corporate social responsibility activities, and counteracting the undermining tactics of the tobacco industry. Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd 745 on behalf of Federation of European Biochemical Societies. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Tobacco control achievements and challenges A. Peruga et al. national tobacco control measures that span across all Table 1. Description of the WHO FCTC articles and their inclusion government sectors. in the MPOWER measures. FTCT MPOWER Policy topic articles measure 2.2. Quadrupling the number of people benefiting from at least one cost-effective General obligations engendered by the 3–5 tobacco control policy since 2007 treaty Demand-side reduction measures 6–14 In 2008, WHO introduced the MPOWER package to Increasing price and tax measures as 6 R assist in implementing the six best-practice cost-effec- effective means to reduce the demand tive interventions defined in the WHO FCTC. The six for tobacco MPOWER measures are as follows: (a) Monitor Implementing effective measures to 8 P protect from exposure to tobacco tobacco use and prevention policies (M); (b) Protect smoke in indoor workplaces, public people from tobacco smoke (P); (c) Offer help to quit transport, indoor public places, and other tobacco use (O); (d) Warn about the dangers of public places tobacco (W); (e) Enforce bans on tobacco advertising, Regulating the contents and emissions 9–10 promotion and sponsorship (E); and (f) Raise taxes on of tobacco products and disclosing tobacco (R) (see Table 1 for an overview of MPO- information on their constituents and WER measures and how they relate to the WHO emissions Banning misleading tobacco packaging 11 W FCTC provisions) [6]. To track the global improve- and labeling and ensuring that tobacco ment in the implementation of MPOWER measures, product packages carry large health WHO measures the level of policy achievement for warnings and messages describing the each measure in each country. In each country, an harmful effects of tobacco use MPOWER measure is considered to be mandated at Promoting public awareness of tobacco 12 W the highest level when the law requires implementing control issues through all available all policy components that render such measure most communication tools Banning of all forms of tobacco 13 E efficacious in reducing the demand for tobacco prod- advertising, promotion, and sponsorship ucts, that is, reducing the prevalence of tobacco use. Supporting the reduction in tobacco 14 O For example, the MPOWER measure to protect the dependence and assisting cessation, population from tobacco smoke is mandated at the including counseling, psychological highest level when the law requires a complete indoor support, nicotine replacement, and smoking ban for all workplaces and public places and education programs not only for some of them. Similarly, the measure to Eliminating all forms of illicit trade in 15–17 tobacco products, prohibiting the sales warn about the dangers of tobacco is mandated at the of tobacco products to or by minors, and highest level when the law requires that health warn- supporting economically viable ings cover an average of at least 50% of the front and alternative activities to tobacco growing back of the package and has four or more desired fea- Addressing the severe risks posed by 18 tures. These features include changing the health warn- tobacco growing to human health and ing periodically or including pictures or pictograms. the environment Tobacco taxes are mandated at the highest level when Holding the tobacco industry liable for 19 any abuses and promoting cooperation excise tobacco taxes amount to at least 75% of the among Parties in legal actions relating to retail price of a cigarette pack. The closer each country liability is to the highest level of policy achievement, the higher Scientifically and technically cooperating 20–22 M is the MPOWER score the country receives. A detailed and communicating among Parties, description of the MPOWER scores has been including tobacco control surveillance explained elsewhere [7]. Managing institutional arrangements and 23–28 About 5 billion people living in 136 countries, an financial resources of the treaty equivalent to 65% of the world’s population, are cur- rently benefiting from at least one of these MPOWER measures implemented at the highest level. This is a comprehensive ban of tobacco advertising, promotion, fivefold increase from the 1.1 billion people benefiting and sponsorship has increased about sixfold between from tobacco control measures back in 2007. 2007 and 2018. The proportion of the world’s popula- The world’s population profiting from a basic com- tion benefitting from a comprehensive smoke-free pol- prehensive policy to assist smoking cessation, or a icy or a legal mandate to have large graphic labels 746 Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License A. Peruga et al. Tobacco control achievements and challenges with strong health warnings on tobacco packages has prevalence despite progress in MPOWER implementa- increased more than eight times in the same period. tion. Another study indicated that the adoption of at While the increase in cigarette taxes is the most least one highest level MPOWER policy in 88 coun- effective tobacco control measure [8], it was also the tries between 2007 and 2014 resulted in almost 22 mil- least applied in 2018. The total population worldwide lion fewer projected smoking-attributable deaths [12]. affected by a cigarette tax representing at least 75% of The health impact of smoke-free policies has been the retail price has almost doubled since 2007. Another impressive. The proportion of people protected by way to look at the impact of tobacco taxes is to assess smoke-free legislations worldwide has increased from whether tax increases are able to decrease the afford- 3.0% in 2007 to 21.1% in 2018 (Table 2). The largest ability of tobacco products. By 2018, 44.3% of the countries in the world report significant decreases in global population lived in countries where cigarettes the proportion of people exposed to secondhand became less affordable in the last 10 years. However, smoke [13–16]. Existing evidence shows that countries most decreases in cigarette affordability were small. that enact national legislative smoking bans reduce the When considering at least a 10% relative decrease in population exposure to passive smoke and benefit cigarette affordability, the world’s population living in from improved health outcomes, specifically of cardio- countries achieving this breakthrough is 3.1% [7]. vascular diseases [17]. Noticeably, the proportion of the world’s population exposed to a best-practice mass media campaign 2.4. Tobacco plain packaging has resisted decreased from 2010 until 2018. Few countries run challenges under trade and investment law mass media campaigns regularly, probably due to the high costs of such campaigns. Only four countries In 2012, Australia became the first country to imple- (Australia, Turkey, the United Kingdom, and Viet ment tobacco plain packaging to counter the tobacco Nam) have run best-practice mass media campaigns industry’s use of packaging for both selling cigarettes repeatedly since 2010. and undercutting health warnings. The Australian leg- islation bans logos, brand imagery, symbols, other images, colors, and promotional text on tobacco prod- 2.3. Reducing the prevalence of smoking and ucts and tobacco product packaging. It also requires exposure to secondhand smoke According to the latest WHO estimates that compared Table 2. Global progress in the implementation of selected smoking prevalence across countries in 2015, the age-s- tobacco control policies at the highest levela. Change between tandardized prevalence of current tobacco smoking 2007 and 2018 in the population living in countries with selected had decreased gradually by 5.9 percentage points since policy in billions and as a percentage of the world’s population. the beginning of the 21st century, that is, a relative reduction of 25% or an average decrease of 0.4 per- 2007 2018 centage points per year. WHO estimates that 19.8% of Policy achievement Billion % Billion % the world’s population aged ≥ 15 years were current Total tax on cigarettes ≥ 75% of 0.5 b 7.6 b 1.0 13.2 smokers in 2015 [9]. Denmark, Norway, and Uruguay retail price were the only countries where current smoking preva- Comprehensive ban of tobacco 0.2 3.0 1.3 17.1 lence among persons aged ≥ 15 years had been advertising, promotion, and reduced by ten or more percentage points between sponsorship 2005 and 2015. During this period, Denmark and Comprehensive smoke-free policy 0.2 3.0 1.6 21.1 Panama approached most closely the endgame preva- Well-designed national antitobacco 2.4c 36.4c 1.7 22.4 lence target of 5%, covering more than half of the gap mass media campaigns National quitline, and both NRT and 0.4 6.1 2.4 31.6 between current smoking prevalence and target [10]. some cessation services cost- A recent study [11] estimated that in countries with covered higher initial tobacco control preparedness, as mea- Strong and large graphic health 0.4 6.1 3.9 51.3 sured by an early MPOWER implementation, the warning on the package prevalence of daily smoking decreased by between 0.39 a The highest level of implementation corresponds to a policy and 0.50 percentage points for each increase in the adopted with all the necessary features to make it as effective as MPOWER score, which indicates the strength of the possible in achieving its intended goals. adopted policies. By contrast, countries with initially b Year corresponds to 2008. low tobacco control preparedness and high daily c Year corresponds to 2010.Source: Reference [8] and own elabora- smoking prevalence seem to be struggling to reduce tion. Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd 747 on behalf of Federation of European Biochemical Societies. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Tobacco control achievements and challenges A. Peruga et al. that graphic health warnings cover 75% of the front expected to hinder a more significant global decrease. and 90% of the back of the tobacco pack [18]. Considering these figures, and that almost one third of Australia’s plain packaging legislation underwent the countries of the world—59 countries in total—have three sets of legal challenges. First, big tobacco com- not yet adopted any MPOWER measures at the high- panies filed a lawsuit in the Australian High Court. est level of achievement, the implementation of cost-ef- Second, Philip Morris Asia sought to bring down the fective tobacco control measures needs to be Australian legislation under an existing investment expedited. treaty between Australia and Hong Kong. Third, Strengthening tobacco denormalization through Cuba, the Dominican Republic, Honduras, Indonesia, smoke-free environments and disseminating plain and Ukraine filed a dispute through the World Trade packaging and large pictorial warnings for all tobacco Organization (WTO). The constitutional challenge products could spearhead progress in many countries. was dismissed in August 2012 [19], and the investment It seems, however, that a few measures will require challenge was rejected in December 2015 [20]. The prompt unique determination and diligence. In our WTO decided in June 2020 that Australia’s plain opinion, bolder moves are needed to: packaging laws are likely to improve public health  significantly increase real prices of all tobacco and that they are not unfairly restrictive to trade [21]. products through tobacco taxes. Since increasing The decisions in the case of Australia are not just a taxes is the most effective tobacco control mea- success for public health. They also bring hope for sure, the tobacco industry devotes many efforts continuing efforts to defend tobacco control policies to derail this measure [23,24]. The main tactics against the attempts of the wealthy tobacco transna- employed by these companies depend on the tax tionals. structure and administration of each country and the type of competition they face from other 3. Immediate challenges for further manufacturers [25]. reducing the burden to tobacco-  disrupt strategies currently applied to engineer attributable diseases the attractiveness of tobacco products by ban- ning ingredients that may increase their palata- The successes described above are significant accom- bility, including additives and particularly plishments. However, key challenges still need to be characterizing flavors. addressed to reduce the burden of tobacco-attributable  ban the most insidious form of tobacco promo- diseases worldwide in a timely manner. tion: the tobacco industry’s corporate social investment or responsibility (CSR) initiatives. 3.1. Accelerating the decline of smoking The tobacco industry has always conceived CSR prevalence as a public relations tool to further its business objectives [26]. It is a form of advertising, pro- The WHO set a relative reduction goal of 30% in motion, and sponsorship that should be banned. tobacco use and smoking for the period between 2010 Whether supporting empowering women [27], and 2025 [22]. Accordingly, the global prevalence of disaster relief and preparedness [28], infectious current smokers should be 15.1% by 2025. However, disease prevention [29], or efforts against based on existing trends, the WHO projects that cur- COVID-19 [30], the tobacco industry’s CSR rent smokers would be 17.1% of the global population activities do little to address the death and suf- by 2025 [7]. Therefore, the projected decrease is not fering caused by tobacco use [31]. fast enough to reach the 2025 reduction goals set by the WHO. To accelerate the implementation of these and other The reduction in smoking prevalence has been, so measures and the decline of smoking, some consider far, attributed primarily to the increase in the total that a harm reduction strategy should be added to the population and not necessarily to a reduction in the existing mix of policies. A harm reduction approach to number of smokers. It is projected that the total num- tobacco control encourages those smokers that cannot ber of smokers will decrease from 1082 million in 2000 or are unwilling to stop smoking to switch to using to 1058 million in 2025, a reduction of about 24 mil- nicotine in a less harmful form than combustible lion or 2.2% [7]. While the number of smokers in the tobacco [32]. The public health community is divided Americas and Europe will substantially decrease, a net over the value of such a strategy within the parameters increase in male smokers in the African, Eastern of the existing alternative products, market forces driv- Mediterranean, and South-East Asian regions is ing the use of all tobacco and nicotine products, the 748 Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd on behalf of Federation of European Biochemical Societies. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License A. Peruga et al. Tobacco control achievements and challenges strength of tobacco control policies, and the room of Therefore, the COVID-19 pandemic highlights the these to significantly and quickly drive a reduction in importance of investing equal efforts in tackling com- smoking [33]. Resolving this debate is a challenge too. municable diseases and NCDs, as the latter impact on Meanwhile, there are at least three things that should the health outcomes of the former, as well as on the be considered to expedite the implementation of the capacity of healthcare systems. WHO FCTC, as discussed below. Tobacco control, and NCD prevention, in general, involves the regulation of industries that produce goods whose consumption may affect human health. 3.2. Positioning tobacco control in the global Some of these industries and their allies are self-serv- health and development agendas ingly reminding us that the priority for global health is The global success of the WHO FCTC will be partially to prevent communicable disease [41] and responding determined by the extent to which governments and quickly and decisively to outbreaks [42] instead of the international community realize that the tobacco tobacco control or NCDs [43,44]. pandemic is a threat to development and the achieve- ment of the United Nations Sustainable Development 3.3. Overcoming the false ‘health versus Goals (SDG) [34]. Tobacco use increases healthcare economy’ dilemma: the need for a whole- costs and decreases productivity. Moreover, it feeds government approach into the vicious circle of poverty. The most disadvan- taged people spend comparatively less on necessities The response to the COVID-19 pandemic has made us such as food, education, and health care to pay for painfully aware of the fallacy of presenting the their addiction to tobacco products [35]. Furthermore, response to health problems as a trade-off between tobacco farming destroys the environment upon which lives saved and the economic cost of trying to save the poorest rely to survive. The large amounts of pesti- those lives—the health versus the economy dilemma. cides and fertilizers required to grow tobacco are toxic Positioning tobacco control within the overall—mainly and pollute water supplies, in addition to the defor- economic—priorities of each government is a chal- estation of their habitat to make room for a nonstaple lenge, mainly given the intricacies of the broader con- crop and to cure tobacco [36]. Despite the inclusion of text of the economic globalization that governments a specific target for implementing the WHO FCTC in must navigate. the SDGs, for most governments, tobacco control Parties to the WHO FCTC recognize that a critical remains merely a health issue instead of a development challenge to implementing the treaty in their countries goal [37]. is the weakness of their multisectoral coordination and Noncommunicable diseases presently make up 7 of the insufficient support to the implementation of the the world’s top ten causes of death, and tobacco use is WHO FCTC from sectors outside health [45]. A a risk factor for many NCDs [38]. However, tobacco whole-government approach is needed to succeed in control is often not prioritized in the health policy declining smoking prevalence. agenda [32]. The global health agenda is presently dominated by the ‘unfinished agenda’ of communica- 3.4. Countering the Tobacco Industry’s Tactics to ble disease and maternal and child health in low- and undermine tobacco control measures middle-income countries. Considering the threats of tobacco use to the public health systems, tobacco con- The interests of the tobacco industry are irreconcilable trol’s contribution to building stronger economies and with tobacco control and public health [46]. Conse- more equitable societies will help to address the ‘unfin- quently, governments should protect the implementa- ished agenda’ and will be crucial for the recovery from tion of their tobacco control policies from the the COVID-19 pandemic in low- and middle-income commercial and other vested interests of the tobacco countries [39]. industry as mandated by the WHO FCTC. Countering The exposure of high-income countries to the the tobacco industry’s tactics to undermine tobacco COVID-19 pandemic has highlighted the importance control measures is not a new challenge [47], but it has of controlling communicable diseases also in these evolved with time. From the same that claimed at nations. However, this should not distract us from the some point that tobacco is not damaging to health fact that COVID-19 has hit the hardest people with [48], nor addictive [49] or denied targeting youth [50], NCDs, for which tobacco use is the main common risk we get now that they are committed to a ‘smoke-free factor. Smoking increases the risk of hospitalization, future’ [51]. Their claims are not credible as long as disease severity, and mortality from COVID-19 [40]. the industry continues to fight proven policies and Molecular Oncology 15 (2021) 744–752 ª 2021 The Authors. Molecular Oncology published by John Wiley & Sons Ltd 749 on behalf of Federation of European Biochemical Societies. 18780261, 2021, 3, Downloaded from https://febs.onlinelibrary.wiley.com/doi/10.1002/1878-0261.12918 by Readcube (Labtiva Inc.), Wiley Online Library on [13/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Tobacco control achievements and challenges A. Peruga et al. programs that reduce smoking. Equally, their procla- References mations are not convincing while they misrepresent 1 U.S. Dept. of Health, Education, and Welfare, Public regulatory agency decisions about the novel tobacco Health Service (1964) Smoking and health: Report of products such as heated tobacco products as less the Advisory Committee to the Surgeon General of the harmful than cigarettes [52]. 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