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In the News
August 10, 2021

WHO Report—Despite Progress in Tackling Tobacco Use, Some Countries Fail to Regulate e-Cigarettes and Other Emerging Products

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum
JAMA Health Forum. 2021;2(8):e212901. doi:10.1001/jamahealthforum.2021.2901

Many nations are making progress in reducing use of tobacco products, but some have not stepped up to tackle newer electronic nicotine delivery products, including e-cigarettes, according to the eighth World Health Organization (WHO) report on the global tobacco epidemic.

Approximately 1.3 billion people use tobacco worldwide, and more than 80% of them live in low- and middle-income countries. Approximately 21% of US adults (nearly 51 million) were users of any tobacco product in 2019, according to a report from the Centers for Disease Control and Prevention.

In most countries, the proportion of people using tobacco has declined, but the number remains high because of population growth. Tobacco is responsible for 8 million deaths a year, including 1 million deaths resulting from exposure to second-hand smoke.

The new report summarizes national efforts to implement 6 WHO-recommended measures known as “MPOWER” that are proven to reduce tobacco use: monitoring tobacco use and preventive measures; protecting people from exposure to tobacco smoke; offering help to quit tobacco use; warning about the dangers of tobacco; enforcing bans on tobacco-related advertising, promotion, and sponsorship; and raising taxes on tobacco.

This report also marks the first time the WHO reports on global tobacco use have included data on electronic nicotine delivery systems, such as e-cigarettes. Thousands of flavors are available for these products, many of which—such as bubble gum, cotton candy, and fruit flavors—are appealing to children and “can increase the palatability of the product and help them be targeted specifically at children and young adults,” the report says.

The aggressive promotion of electronic nicotine delivery systems to children and adolescents is especially concerning, given that their use “poses the risk of nicotine addiction,” the report says, pointing to research suggesting that young people who experiment with such products are up to 3 times more likely to subsequently become regular users of conventional cigarettes and thereby become vulnerable to smoking-related health risks.

In addition, there is growing evidence that these products are not harmless, the report notes, citing evidence for effects on the cardiovascular and respiratory systems. It also cites research suggesting that “nicotine can have deleterious impacts on brain development, leading to long-term consequences for children and adolescents in particular.”

The report describes “steady progress” on tobacco control since the publication in 2008 of the first WHO report on the tobacco epidemic, with some 5.3 billion people now covered with at least 1 WHO-recommended tobacco control measure, 4.2 billion more than were covered in 2007. Half the global population and more than half of all countries (4.4 billion people, in 98 countries) are now covered by at least 2 MPOWER measures “at the highest level of achievement”—meaning that a policy has been adopted with all of the components needed to make it as effective as possible in accomplishing its intended goals.

However, some of the MPOWER measures have been more widely adopted than others. For example, more than half the world’s population (60%) are exposed to graphic health warnings on tobacco products, such as images of lungs with visible smoking-related damage. In contrast, the policy of raising prices of tobacco products through taxation—the most effective way to reduce tobacco use—has the lowest population coverage, with only 13% of the world’s population protected by taxes at the “best-practice level.” In addition, the COVID-19 pandemic affected one MPOWER measure—monitoring tobacco use—hindering data collection efforts in most countries as well as the release of results for surveys completed in 2018 and 2019.

About 1 in 4 countries—49 of 195 nations—have not yet adopted any MPOWER measures.

The report also highlights threats posed by electronic nicotine delivery systems and challenges in regulating them.

“These products are hugely diverse and are evolving rapidly,” Rüdiger Krech, DrPh, MPH, Director of WHO’s Health Promotion Department, noted in a WHO news release. “Some are modifiable by the user so that nicotine concentration and risk levels are difficult to regulate. Others are marketed as ‘nicotine-free’ but, when tested, are often found to contain the addictive ingredient.”

Of 195 countries, 111 regulate electronic nicotine delivery systems in some fashion, but 84 have no bans or regulation to address them. Some 32 nations have banned the sale of these products, but only 30 completely prohibit their use in all indoor public places, workplaces, and public transport.

Among the countries where electronic nicotine delivery systems are not banned, only 42% have age restrictions to their sale and purchase, and only 9 countries have regulations restricting flavorings.

Proponents of electronic nicotine delivery systems claim that the presence of “less-harmful” alternatives can help reduce tobacco use. However, the WHO report says, such products are marketed to attract new users—and are not limited to tobacco users who want to quit—and to “misinform the public about the risks associated with their use in the absence of robust evidence (or indeed in the face of growing evidence to the contrary).”

Electronic nicotine delivery systems “currently pose significant challenges to public health and could undermine some of the hard-won progress in tobacco control achieved to date,” the report says.

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Article Information

Published: August 10, 2021. doi:10.1001/jamahealthforum.2021.2901

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Stephenson J. JAMA Health Forum.

Corresponding Author: Joan Stephenson, PhD, Consulting Editor, JAMA Health Forum (Joan.Stephenson@jamanetwork.org).

Conflict of Interest Disclosures: None reported.

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