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Could international human rights obligations motivate countries to implement tobacco cessation support?



Background and aims: The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) seeks to realize the right to health through national tobacco control policies. However, few States have met their obligations under Article 14 of the FCTC to develop evidence-based policies to support tobacco cessation. This article examines how human rights obligations could provide a legal and moral basis for States to implement greater support for people who use tobacco to overcome their addiction. Analysis: The United Nations (UN) has a well-established legal framework for promoting human rights, looking to the right to health to realize health autonomy. Where addiction undermines autonomy, it is widely acknowledged that addiction presents a significant barrier to cessation for individuals who use tobacco, undermining the right to health. The UN human rights system could thus provide a complementary basis for monitoring State obligations under Article 14 of the FCTC, identifying challenges to FCTC implementation and motivating States to support tobacco cessation. Conclusions: The United Nations' human rights system offers a mechanism that could be used to monitor Framework Convention on Tobacco Control implementation in national policy, facilitating accountability for the progressive realization of cessation support.
Could international human rights obligations motivate
countries to implement tobacco cessation support?
Benjamin Mason Meier
| Martin Raw
| Donna Shelley
| Chris Bostic
Anahita Gupta
| Kelsey Romeo-Stuppy
| Laurent Huber
Gillings School of Global Public Health,
University of North Carolina at Chapel Hill,
School of Global Public Health, New York
University, New York, NY, USA
International Centre for Tobacco Cessation,
Action on Smoking and Health (ASH),
Washington, DC, USA
Benjamin Mason Meier, Gillings School of
Global Public Health, University of North
Carolina at Chapel Hill, 103 Abernethy Hall,
Chapel Hill, North Carolina 27599, USA.
Background and aims: The World Health Organization (WHO) Framework Convention
on Tobacco Control (FCTC) seeks to realize the right to health through national tobacco
control policies. However, few states have met their obligations under Article 14 of the
FCTC to develop evidence-based policies to support tobacco cessation. This article
examines how human rights obligations could provide a legal and moral basis for states
to implement greater support for individuals to overcome their addiction to tobacco.
Analysis: The United Nations (UN) has a well-established legal framework for promoting
human rights, looking to the right to health to realize health autonomy. Where addiction
undermines autonomy, it is widely acknowledged that addiction presents a significant
barrier to cessation for individuals who use tobacco, undermining the right to health.
The UN human rights system could, therefore, provide a complementary basis for moni-
toring state obligations under Article 14 of the FCTC, identifying challenges to FCTC
implementation and motivating states to support tobacco cessation.
Conclusions: The United Nationshuman rights system offers a mechanism that could be
used to monitor Framework Convention on Tobacco Control implementation in national
policy, facilitating accountability for the progressive realization of cessation support.
Addiction, cessation, Framework Convention on Tobacco Control, human rights, nicotine, right to
health, World Health Organization
The World Health Organization (WHO) has sought to challenge the glob-
alization of tobacco through international law, leading WHO member
states to adopt the Framework Convention on Tobacco Control (FCTC).
The FCTC is an evidence-based treaty that reaffirms the human right of
all people to the highest standard of health and asserts the importance
of policies to influence the supply of and demand for tobacco. Although
the FCTC has achieved some success in limiting the initiation of tobacco
use, this international legal effort has been less successful in promoting
the adoption of cessation measures to ensure that people who use
tobacco receive effective support to free themselves from their harmful
addiction to tobacco. Article 14 of the FCTC obligates states to take
effective measures to promote cessation of tobacco use and adequate
treatment for tobacco dependence, but few states have fully implemen-
ted Article 14 in national policy. Individuals who use tobacco, addicted
to tobacco and limited in their autonomy, have, therefore, been denied
their inherent dignity and fundamental rights. International human rights
law provides a path to recognize tobacco cessation as central to tobacco
control, supporting the 1.3 billion addicted individuals who use
tobacco throughout the world. With the right to health supporting
efforts to free individuals from harmful addictions, health and human
rights accountability mechanisms can support Article 14 implementation,
framing tobacco cessation as a human rights obligation.
In focusing on tobacco cessation policy, this article examines
implementation of FCTC Article 14 and the Guidelines for
Received: 8 February 2022 Accepted: 20 June 2022
DOI: 10.1111/add.15990
Addiction. 2022;18. © 2022 Society for the Study of Addiction. 1
Implementation of Article 14 (Article 14 Guidelines). Although addres-
sing a wide array of approaches to cessation, this article does not
examine the emergence of alternative nicotine delivery products,
including electronic cigarettes, which are beyond the scope of this
article. Such commercial products did not exist when the FCTC was
negotiated, although the idea that nicotine and tobacco products exist
on a continuum of risk was already established. With the widespread
availability of new non-combustible nicotine products, the product
and policy landscape for cessation has become more complex.
Research to understand nicotine addiction continues to evolve with
the advent of these new nicotine delivery products, yet evidence-
based treatment remains out of reach for most people who use
tobacco, particularly in low- and middle-income countries. Therefore,
implementing Article 14 remains a public health priority for realizing
the right to health, raising an imperative to understand the limited
implementation of Article 14 and to consider how human rights obli-
gations can support national cessation policies.
This article recognizes the need to free individuals from tobacco
addiction and the health harms of tobacco use, realizing human rights
through tobacco cessation. Because addiction limits individual choice,
the article opens by examining international legal obligations under the
human right to health to ensure access to tobacco cessation support.
Drawing from cessation guidelines developed under the FCTC, we ana-
lyze the progress made by states in implementing Article 14, finding this
progress to have been slow in low-, middle- and high-income states. To
strengthen international accountability for the progressive realization of
rights, this article assesses how the WHO FCTC can work alongside the
United Nations (UN) human rights system to support implementation of
effective tobacco cessation measures. We conclude that improving
tobacco cessation support will require a coordinated effort across global
health and human rights governance to realize the highest attainable
standard of health, looking to human rights monitoring mechanisms to
facilitate state accountability for cessation policy.
In the 1946 WHO Constitution, states proclaimed for the first time
that the enjoyment of the highest attainable standard of health is one
of the fundamental rights of every human being[1]. This human right
to health came to be codified by the UN under the 1966 International
Covenant on Economic, Social and Cultural Rights (ICESCR), outlining
state obligations to realize the prevention, treatment and control of
epidemic, endemic, occupational and other diseases[2]. States bear
obligations to progressively realizethe rights in the ICESCR, and in
accordance with this principle of progressive realization, a state must
take steps to uphold the right to health to the maximum of its avail-
able resources, with a view to achieving progressively the full realiza-
tion of the rights[2]. Recognizing that the full realization of economic
and social rights depends on financial resources, the principle of pro-
gressive realization provides a degree of flexibility to states while
requiring continuing and progressive steps to implement rights in
accordance with their available resources. To progressively realize the
right to health over time, the UN Committee on Economic, Social and
Cultural Rights (CESCR), the legal body charged with drafting official
interpretations of and monitoring state compliance with the ICESCR,
found in 2000 that states bear obligations to discourage production,
marketing and consumption of tobacco[3]. The right to health
thereby imposes an obligation on states to safeguard the health of
those addicted to tobacco, supporting individual autonomy, healthy
behaviours and vulnerable populations through the progressive reali-
zation of tobacco cessation policies [4].
Addiction limits individual autonomy
The right to health upholds an entitlement to enjoy conditions that will
maximize the potential for individuals to enjoy healthand the freedom
of individuals to make choices about their own health[3]. However, the
choiceto use tobacco, especially smoking, is largely shaped by tobacco
industry efforts to manipulate chemical, sociocultural and structural fac-
tors that enhance nicotine addiction and undermine individual decision
making [5]. Despite widespread desire to quit smoking, few will achieve
long term abstinence without support [6, 7]. The use of tobacco, initiated
primarily in adolescence, but maintained by addiction, is not an informed
and voluntary choice consistent with the right to health [8]. Even as the
tobacco industry has tried to co-opt human rights rhetoric, cynically
using the language of choiceto advance its corporate objectives [9],
human rights obligations require states to support individuals to free
themselves from addiction to harmful tobacco products [10].
State obligations to support healthy behaviours
through cessation
Under the right to health, states bear an international legal obligation
to facilitate environments in which individuals can make autonomous
decisions about their health. Recognizing the ways in which individual
choice has been impaired by youth targeting, industry marketing and
addiction enhancing (engineering cigarettes to increase addictiveness),
states must progressively realize measures under the right to health to
protect individuals from corporate interference with healthy decision
making adopting measures that discourage tobacco use and support
cessation [11, 12]. Cessation support helps to overcome the influence
of nicotine addiction and supports the restoration of individual auton-
omy over health. Among tobacco control measures, only adult cessa-
tion provides significant short- to medium-term population health
benefit [13]. Yet, governments often lack the political will to resist
industry influence and promote cessation, with tobacco corporations
lobbying relentlessly to weaken national tobacco control policy, includ-
ing tobacco taxes, which have been among the most effective
approaches for reducing tobacco use and could provide resources for
cessation support [14, 15]. To restore individual autonomy and self-
determination under the right to health, states must implement the ces-
sation measures set out in FCTC Article 14 and its guidelines [16, 17].
Population-level prevention to support vulnerable
Yet, despite these cessation obligations, various reports on FCTC imple-
mentation show that states have prioritized population-level prevention
measuresincluding taxation policy, age restrictions, smoke-free policies,
health warnings, advertising bans and education campaignswhile
neglecting cessation support measures [18]. Because prevention efforts
alone are insufficient to realize the inherent dignity of vulnerable popula-
tions addicted to tobacco, the integration of individual support and
population-level interventions can create an environment that both pro-
motes quitting and offers support to achieve cessation, enabling individ-
uals who use tobacco to make conscious, autonomous decisions about
their health behaviours [19]. Such an integrated approach to cessation
takes account of vulnerable populationsincluding the effects of pov-
erty, disadvantage and other social determinants of healthto ensure
the progressive realization of the right to health [20].
FCTC Article 14 obligates states to develop effective measures to
promote tobacco cessation and tobacco dependence treatment,
including in (but not limited to) national health systems, and to collab-
orate internationally to facilitate cessation accessibility and
Box: FCTC Article 14
1. Each Party shall develop and disseminate appropriate,
comprehensive and integrated guidelines based on scien-
tific evidence and best practices, taking into account
national circumstances and priorities, and shall take
effective measures to promote cessation of tobacco use
and adequate treatment for tobacco dependence.
2. Toward this end, each Party shall endeavour to:
a. design and implement effective programmes aimed at
promoting the cessation of tobacco use, in such loca-
tions as educational institutions, health care facilities,
workplaces and sporting environments;
b. include diagnosis and treatment of tobacco dependence
and counselling services on cessation of tobacco use in
national health and education programmes, plans and
strategies, with the participation of health workers,
community workers and social workers as appropriate;
c. establish in health care facilities and rehabilitation
centres programmes for diagnosing, counselling, pre-
venting and treating tobacco dependence; and
d. collaborate with other Parties to facilitate accessibil-
ity and affordability for treatment of tobacco depen-
dence including pharmaceutical products pursuant to
Article 22. Such products and their constituents may
include medicines, products used to administer medi-
cines and diagnostics when appropriate [21].
The FCTCs preamble recognizes that cigarettes and some other
products containing tobacco are highly engineered to create and
maintain dependence;however, Article 14, the only article of the
FCTC on cessation, presents limited guidance for policy reforms, bud-
getary commitments and monitoring requirements to promote cessa-
tion. Despite the Article 14 obligation in paragraph 1 to take
effective measures to promote cessation of tobacco use and adequate
treatment for tobacco dependence,the specific recommendations in
paragraph 2 use nonobligatory caveats (e.g. shall endeavour to,’‘as
appropriate,and when appropriate), which serve to weaken state
obligations for cessation. Further, Article 14 does not use the words
addictionor choice,two words that form the public health and
human rights foundation for cessation interventions[15]. This ambigu-
ous language may enable states to shirk their Article 14 obligations.
Therefore, even as the FCTC recallsthe human right to health in its
preamble, Article 14 of the FCTC fails to ground tobacco cessation in
human rights under international law, neglecting the rights of vulnera-
ble individuals and necessitating subsequent guidelines to frame
national obligations to protect individuals from tobacco addiction.
The Article 14 Guidelines interpret this article and detail what
states should do to meet their FCTC obligations. In October 2010, the
fourth FCTC Conference of the Parties (COP 4) adopted these guide-
lines to assist Parties in meeting their obligations under Article 14 of
the FCTCon the basis of the best available scientific evidence and
taking into account national circumstances and priorities[22]. Provid-
ing detailed guidance to help states improve cessation support to aid
those addicted to tobacco, the guidelinesunderlying considerations
recognize the: addictive nature of tobacco, importance of implement-
ing cessation synergistically with other tobacco control measures,
need for accessible and affordable treatments, importance of active
partnership with civil society, protection from commercial interests of
the tobacco industry and central role of healthcare systems in promot-
ing tobacco cessation [23]. Although the guidelines do not explicitly
look to human rights as a foundation for cessation interventions, they
draw on human rights norms and principles to address tobacco
The guidelines are organized in three sections:
1. The development of core infrastructures to support tobacco cessa-
tion, including: analyzing the countrys capacity and resources and
using existing systems and resources as much as possible;
strengthening national coordination; developing national guide-
lines; addressing tobacco use by healthcare workers; and ensuring
that all people who use tobacco are identified within the health-
care system and offered at least brief advice.
2. The key components of a system to help people who use tobacco
to quit: population level approaches that deliver cessation informa-
tion (e.g. mass communication); brief advice in healthcare interac-
tions; free quitlines; and individual cessation support, including
specialized treatment and accessible, affordable and scientifically
proven medications.
3. A stepwise approach to developing cessation support, wherein
countries with limited resources are urged to initially implement
broad based low-cost measures, through core system infrastruc-
tures, including screening all patients for tobacco use and offering
brief cessation advice, and later progressively implementing more
comprehensive measures and intensive treatments (including
behavioural support and medications) as resources become avail-
able [17, 24].
The guidelines conclude with recommendations for monitoring
cessation implementation, allowing for the evaluation of trends, assess-
ment of state obligations and identification of areas where international
assistance and cooperation may be necessary [21]. Monitoring national
cessation implementation provides a path to facilitate accountability
for state efforts; however, the Article 14 Guidelines have not led to
widespread cessation policy advancements across nations.
Many states have neglected to implement Article 14, failing to estab-
lish policies to progressively realize the right to health through cessa-
tion support. This failure to support those addicted to tobacco
predated the Article 14 Guidelines, with many states prioritizing pre-
vention over cessation [25], and this trend has continued even after
the establishment of the guidelines [17].
Cessation support has been neglected
WHOsReport on the Global Tobacco Epidemic, 2021 concludes suc-
cinctly that support for quitting remains low[26]. An in-depth survey
of cessation support across countries has illustrated the relatively low
level of cessation support provision. For example, only a third of coun-
tries had an official national cessation strategy, less than half had
national guidelines and only about a quarter had a cessation budget,
national quitline or specialized treatment services [17]. Despite an
opportunity to address tobacco cessation during the coronavirus dis-
ease (COVID-19) pandemic, with tobacco use leading to higher rates
of severe illness, few states have taken immediate steps to advance
cessation in the pandemic response [27].
The Article 14 Guidelines outline specifically what states should
do to implement cessation support under the FCTC [28], but state
progress has remained limited [29]. An independent survey found
that cessation support was often linked to national income level
[30]. No low-income country had developed a defined budget for
tobacco cessation, a national telephone helpline, an official national
cessation strategy or national cessation guidelines, with some coun-
tries looking entirely to non-governmental organizations (NGOs) to
provide tobacco cessation support. Although not surprising, these
findings possibly reflect a lack of recognition of the cost effective-
ness and affordability of cessation interventions [31]. Governments,
especially in low- and middle-income countries, are deterred by the
perceived cost of cessation support [27], despite the fact that many
cessation interventions are broadly applicable and low cost [30].
Beyond resource constraints, the stigmatization of people who
smoke has reinforced opposition to addressing tobacco addiction,
with this lack of empathy for those who smokefailing to see those
addicted to tobacco as equal in dignity and rightsposing a challenge
for state expenditures and cessation support. This limited Article 14
implementation has exposed a lack of political will to address tobacco
addiction and left healthcare systems unequipped to deliver tobacco
cessation interventions [32]. Despite such limitations in sustained
funding, there have been initial efforts by NGOs and select states to
advance the right to health through cessation policy.
NGO efforts to promote cessation support
NGOs have played a key role in supporting national cessation mea-
sures, including developing tools to help states meet the Article 14
Guidelines. Through these tools, NGOs have supported governments
(particularly in low- and middle-income countries) in establishing inter-
ventions for tobacco cessation and facilitating accountability for FCTC
implementation [33]. They have drafted model legislation, helped
develop national cessation strategies and guidelines, provided training
for government officials and healthcare workers, supported quitlines
and held workshops to address implementation obstacles [34]. The
Framework Convention Alliance (FCA) (bringing together over 500
tobacco control NGOs from over 90 countries) has shared cessation
knowledge globally and created resources to aid states in implement-
ing Article 14 [32]. These NGO tools have assisted states to imple-
ment Article 14 through the development of a National Situation
Analysis, guidance on drafting national cessation guidelines and a
model national cessation strategy [35]. Such technical support from
NGOs has helped shape national cessation policy, enabling some
states to implement Article 14 more comprehensively.
State implementation to progressively realize
There has arisen a range of policies across states in implementing
FCTC cessation obligations, as states with divergent capacities have
pursued differential obligations based on their financial resources and
political will.
Low-income states have proven least likely to implement Article
14, as these countries face limited availability of cessation
resources. In Haiti, for example, there are no telephone quitlines
for live assistance with cessation, nicotine replacement therapies
(NRTs) are not legally sold and cessation support is unavailable in
health facilities [36]. Even where there is political will, such low-
income countries may require international assistance to meet
their right to health obligations for individuals facing addiction to
tobacco [37].
Middle-income states have offered more comprehensive cessa-
tion support. Implementing strong cessation interventions under
financial constraints, Vietnams Tobacco Control Fund has been
able to allocate tobacco taxation resources to provide a sustain-
able source of cessation funding [38]. By budgeting additional
cessation resources, middle-income countries have expanded
provider training to aid cessation through: national telephone
quitlines, clinical cessation support (such as health provider
advice) [3941] or even subsidized pharmacotherapy (or NRT)
purchases [42, 43].
High-income states, leveraging greater resources toward cessa-
tion support, have been able to implement Article 14 more com-
prehensively in fulfilling their obligations under the right to
health. New Zealand has implemented cessation through: domes-
tic guidelines for healthcare professionals to provide cessation
support (including guidance on provider training), the integration
of behavioural support and subsidized NRT (including telephone
quitlines and text-based support) and international assistance to
respond to tobacco dependence (in other countries) [44, 45].
With tobacco cessation integrated into all levels of healthcare,
high-income countries have pursued expanded education on ces-
sation (providing behavioural support to the public and especially
vulnerable populations), diagnosis and treatment of tobacco
dependence (across all specialties) and financial assistance for
cessation support (subsidizing tobacco dependence treatment
and NRT) [46].
This gradient of cessation support, reflective of the approach taken in
the Article 14 Guidelines, points to the ways in which increasing eco-
nomic resources improve state capacity to progressively meet cessa-
tion obligations; however, it is clear that funding alone does not
determine state commitment to cessation. Where there is political
will, low- and middle-income countries have developed low-cost inter-
ventions and institutional reforms to promote cessation. Such institu-
tional reforms, as recommended in the Article 14 Guidelines, provide
a path to transparently allocate additional funds to tobacco depen-
dence treatment dedicating tobacco taxation resources to cessation
interventions, designating government representatives responsible for
cessation, incorporating tobacco cessation in health worker training
and developing a national tobacco cessation strategy and national
guidelines [24]. Given these cost-effective avenues for cessation sup-
port, expense need not be the primary obstacle for tobacco cessation,
with political will serving as a crucial determinant of cessation imple-
mentation under Article 14 and with international monitoring neces-
sary to identify challenges and facilitate accountability for the
progressive realization of the right to health [31].
Where states must take steps over time to progressively implement
cessation support, efforts to facilitate accountability for these changes
will require periodic assessment. These assessments can be provided
through complementary monitoring mechanisms in global health gov-
ernance and human rights governance [47].
Global health governance through FCTC monitoring
In facilitating accountability through WHO governance, the FCTC
Article 14 Guidelines recommend specific process and outcome mea-
sures to monitor cessation, allowing states to develop measurable
objectives, determine the required resources and identify indicators of
progress [21]. These objectives can be based on WHOs country-spe-
cific guidelines for implementing the FCTC, which provide a founda-
tion for WHO monitoring of FCTC implementation [48]. Assessments
of these cessation policy measures can be undertaken through the
existing FCTC monitoring systems: the Party Report system (through
which states report implementation in a questionnaire) and WHOs
Report on the Global Tobacco Epidemic(MPOWER).
However, these FCTC monitoring instrumentslacking engage-
ment from civil society, constructive dialogue with government repre-
sentatives and concluding observations to assess implementationdo
not provide validated reporting systems and effective compliance
mechanisms to facilitate accountability for Article 14. (For example,
the Party Report questionnaire is very long, completed by busy gov-
ernment officials pressed for time and lacking civil society input,
review processes and feedback mechanisms. Although MPOWER
seeks to provide more robust monitoring, it has very few, poorly
defined cessation items.) Human rights can support this FCTC moni-
toring. With a human rights decision on the agenda at the upcoming
FCTC Conference of the Parties (COP 10), this human rights focus
provides an opportunity to reaffirm the contribution of the FCTC to
human rights objectives and the United Nations 2030 Agenda for Sus-
tainable Development. The upcoming COP can also help to highlight
the need for cessation support as part of an effective human rights-
based approach to tobacco control, andin facilitating accountability
for cessation supportto link cessation support to human rights moni-
toring mechanisms. In monitoring the progressive realization of human
rights for those addicted to tobacco, it is imperative that implementa-
tion of Article 14 be reviewed simultaneously through the UN human
rights system.
Human rights governance to assess progressive
Human rights governance provides complementary monitoring mech-
anisms, applying international pressure on governments and holding
states accountable for the progressive realization of health-related
human rights. In facilitating accountability for human rights obligations
to support tobacco cessation, UN systems of human rights monitoring
are exercised through:
Human rights treaty bodies With the CESCR respon-
sible for reviewing implementation of the right to
health under the ICESCR, this treaty body has issued
reporting guidelines to frame state periodic reporting,
looking to FCTC standards to frame tobacco control
obligations and providing a basis to monitor the pro-
gressive realization of the right to health under Article
14 [49, 50], with advocates already engaging with the
CESCR to support FCTC implementation [51] and the
Committee on the Elimination of Discrimination
against Women to prevent and reduce nicotine and
tobacco addiction among girls and women[52].
The Universal Periodic Review (UPR) Monitoring
and review of national tobacco cessation efforts can
be furthered by the Universal Periodic Review, which
works through the UN Human Rights Council to assess
human rights realizationacross all treaties and in all
countriesand has proven effective in approaching
tobacco control through the human right to health,
with the UPR additionally advancing health through its
focus on, inter alia, nutrition security, disease surveil-
lance and sexual and reproductive health and rights
[53, 54].
UN special rapporteurs In evaluating the realization
of rights, UN special rapporteurs review human rights
implementation by conducting fact-finding missions to
individual countries, thereafter publishing reports
about the realization of human rights, conclusions on
human rights implementation, and recommendations
for reform,[46] with the UN Special Rapporteur on
the right to health having long examined tobacco con-
trol policies in national missionsreferencing FCTC
implementation, tobacco marketing and trade restric-
tions [55]and developed thematic reports on issues
ranging from mental health to neglected tropical dis-
eases [56].
In comparison with FCTC reporting processes, human rights mon-
itoring is more robust, analytic and impactful. Although relying on
state self-reporting, human rights institutions also consider indepen-
dent reports from civil society. This reporting is not the end of the
process, but the beginning. Reports are reviewed publicly, and human
rights institutions question governments and recommend reforms.
These complementary human rights review mechanisms, with atten-
tion to multisectoral government responsibilities and participation
from civil society advocates, provide an institutional basis to address
tobacco cessation through state realization of the right to health.
Given the periodic nature of human rights monitoring, follow-up is
built in, with each review building from previous reviews. This recur-
ring review process can provide an assessment of a states progressive
realization of cessation support, with monitoring processes recogniz-
ing best practices in cessation, identifying challenges in national imple-
mentation and facilitating accountability through naming and
shamingreviewing implementation publicly, publicizing national
limitations and motivating state action.
The FCTC offers a framework to interpret state obligations to pro-
gressively realize the human right to health, with Article 14 and its
guidelines providing a basis to clarify state obligations to ensure
that those addicted to tobacco receive cessation support. However,
Article 14 implementation has been limited. The right to health pro-
vides an alternative basis under international law to recognize the
inherent dignity of those addicted to tobacco, implement FCTC
obligations under Article 14 and facilitate state accountability. To
improve and accelerate cessation support, the tobacco control and
human rights communities must work together to advance comple-
mentary monitoring processes with civil society participation,
meaningful state dialogue and detailed concluding recommendations
serving as a foundation for accountability in cessation policy. Ensur-
ing that those who use tobacco have the best possible access to
cessation support, with cessation support attainable in all countries
at all levels of development, will require political will and govern-
ment accountability to progressively realize the highest attainable
standard of health.
We are grateful to Robert West for his review of this article.
Benjamin Mason Meier: Conceptualization; formal analysis. Martin
Raw: Conceptualization; formal analysis. Donna Shelley: Conceptuali-
zation; formal analysis. Chris Bostic: Conceptualization. Anahita
Gupta: Investigation. Kelsey Romeo-Stuppy: Conceptualization.
Laurent Huber: Conceptualization.
Benjamin Mason Meier
Martin Raw
1. World Health Organization. Constitution of the World Health Orga-
nization 1946.5444444444.
2. International Covenant on Economic Social and Cultural Rights
(ICESCR). G.A. Res. 2200. 1966.
3. United Nations Economic and Social Council. General Comment
14, para. 51. 2000.
4. Graen L. Advancing tobacco control with human rights. Public Health
Panorama. 2020;6:25260.
5. Kalant H. Nicotine as an addictive substance. Nicotine Public Health.
6. Henninfield JE, Faro RV. Tobacco use as drug addiction: The scien-
tific foundation. Nicotine Tob Res. 1999;1:S315.
7. Xi B, Liant Y, Liu Y, Yan Y, Zhao M, Ma C, et al. Tobacco use and
second-hand smoke exposure in young adolescents aged 1215
years: Data from 68 low-income and middle-income countries. Lan-
cet Glob Health. 2016;11(4):795805.
8. Schmidt A. Is there a human right to tobacco control? Human Rights
and Tobacco Control 2020.
9. Jacobson P, Soliman S. Co-opting the health and human rights move-
ment. J Law Med Ethics. 2002;30:705715.
10. Sircar N, Bialous S. Is the tobacco industrys human rights makeover
growing bolder? Tob Control. 2021.
11. Toebes B, Patterson D. Human Rights and Non-Communicable Dis-
eases: Controlling Tobacco and Promoting Healthy Diets. Founda-
tions of Global Health & Human Rights 2020.
12. Nyatsanza S. Using section 27 to open up the accessibility of
smoking cessation health services in South Africa. S Afr J Bioeth
Law. 2019;12(2):5760.
13. World Bank. Curbing the epidemic: Governments and the economics
of tobacco control. 1999.
14. Hoe C, Kennedy RD, Spires M, Tamplin S, Cohen J. Improving
the implementation of tobacco control policies in low-and
middle-income countries: A proposed framework. BMJ Glob
Health. 2019;4(6):e002078.
15. World Health Organization. Earmarked Tobacco Taxes: Lessons
Learnt from Nine Countries. 2016.
16. Meier BM. Breathing life into the framework convention on tobacco
control: Smoking cessation and the right to health. Yale J Health
Poly, L Ethics. 2005;5:13792.
17. Wu C. State responsibility for tobacco control: The right to health
perspective. Asian J WTO Intl Health L & Poly. 2008;3:379-421.
18. Nilan K, Raw M, McKeever TM, Murray RL, McNeill A. Progress in
implementation of WHO FCTC article 14 and its guidelines: A survey
of tobacco dependence treatment provision in 142 countries. Addic-
tion. 2017;112:202331.
19. Meier BM, Shelley D. The fourth pillar of the framework convention
on tobacco control: Harm reduction and the international human
right to health. Public Health Rep. 2006;6:494500.
20. Ruger J. Global tobacco control: An integrated approach to global
health policy. Development (Society for International Development).
21. World Health Organization. Framework Convention on Tobacco
Control, art. 14. 2003.
22. World Health Organization. FCTC/COP4 Guidelines for implementa-
tion of Article 14 of the WHO Framework Convention on Tobacco
Control. 2010.
23. Raw M. Framework convention on tobacco control (FCTC) article
14 guidelines: A new era for tobacco dependence treatment. Addic-
tion. 2011;106(12):20557.
24. Romeo-Stuppy K, Dresler C, Bostic C, Healton C, Huber L, Lando H,
et al. The urgent need for a human rights approach to improving
smoking cessation treatment. 2020.
25. Bitton A, Raw M, Richards A, McNeill A, Rigotti N. A comparison of
four international surveys of tobacco dependence treatment provi-
sion: Implications for monitoring the framework convention on
tobacco control. Addiction. 2010;105:218491.
26. World Health Organization. WHO Report on the Global Tobacco
Epidemic, 2021: Addressing New and Emerging Products. 2021.
27. Ahluwalia I, Myers M, Cohen J. COVID-19 pandemic: An opportunity
for tobacco use cessation. Lancet. Public Health. 2020;5(11). https://
28. Raw M, Ayo-Yusuf O, Chaloupka F, Fiore M, Glynn T, Hawari F, et al.
Recommendations for the implementation of WHO framework con-
vention on tobacco control article 14 on tobacco cessation support.
Addiction. 2017;112(10):17038.
29. Raw M, Mackay J, Reddy S. Time to take tobacco dependence treat-
ment seriously. Lancet. 2016;387(10017):4123.
30. Piné-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A
survey of tobacco dependence treatment services in 121 countries.
Addiction. 2013;108(8):147684.
31. West R, Raw M, McNeill A, Stead L, Aveyard P, Britton J, et al.
Healthcare interventions to promote and assist tobacco cessation: A
review of efficacy, effectiveness and affordability for use in national
guideline development. Addiction. 2015;110:1388403. https://doi.
32. Shelley D, Kyriakos C, McNeill A, Murray R, Nilan K, Sherman S, et al.
Challenges to implementing the WHO framework convention on
tobacco control guidelines on tobacco cessation treatment: A quali-
tative analysis. Addiction. 2020;115(3):52733.
33. Sparks M. Governance beyond governments: The role of NGOs in the
implementation of the FCTC. Glob Health Promot. 2010;17(1):6772.
34. Frieden T, Bloomberg M. How to prevent 100 million deaths from
tobacco. Lancet. 2007;369(9574):175861.
35. ASH. International Centre for Tobacco Cessation 2022. https://ash.
36. World Health Organization. WHO report on the global tobacco epi-
demic; Country Profile Haiti 2009.
37. Kirenga B, Jones R, Muhofa A, Nyakoojo G, Williams S. Rapid assess-
ment of the demand and supply of tobacco dependence pharmaco-
therapy in Uganda. Public Health Action. 2016;6(1):357. https://
38. Ngan T, Huyen D, Minh HV, Wood L. Establishing a tobacco control
fund in Vietnam: Some learnings for other countries. Tob Control.
39. Agaku I, Egbe C, Ayo-Yusuf O. Utilisation of smoking cessation aids
among south African adult smokers: Findings from a national survey
of 18 208 south African adults. Fam Med Community Health. 2021;
40. Batini C, Ahmed T, Ameer S, Kilonzo G, Ozoh OB, van Zyl-Smit RN.
Smoking cessation on the African continent: Challenges and oppor-
tunities. Afr J Thorac Crit Care Med. 2019;25(2):4648. https://doi.
41. Tadzimirwa G, Day C, Esmail A, Cooper C, Kamkuemah M, Dheda K,
et al. Challenges for dedicated smoking cessation services in devel-
oping countries. S Afr Med J. 2019;109(6):431436.
42. WHO FCTC Implementation Database. Jordan 2016.
43. Madaeen S, Obeidat N, Adeinat M. Using cost-effectiveness analysis
to support policy change: Varenicline and nicotine replacement ther-
apy for smoking cessation in Jordan. J Pharm Policy Pract. 2020;
44. Ministry of Health. The New Zealand Guidelines for Helping People
to Stop Smoking. 2014.
45. Price L, Allen M. New Zealand: Effective Access to Tobacco Depen-
dence Treatment.
46. World Health Organization. 2020 - Core Questionnaire of the
Reporting Instrument of WHO FCTC. 2020.
47. Meier B, Huffstetler H, Bueno de Mesquita J. Monitoring and Review
to Assess Human Rights Implementation. Foundations of Global
Health & Human Rights 2020.
48. World Health Organization. The 2020 reporting cycles on the WHO
FCTC and the Protocol launched. 2020.
49. Meier B, Gomes V. Human Rights Treaty Bodies Monitoring, Inter-
preting, and Adjudicating Health-Related Human Rights. Human
Rights in Global Health: Rights-Based Governance for a Globalizing
World 2018.
50. Meier B, De Milliano M, Chakrabarti A, Kim Y. Accountability for the
human right to health through treaty monitoring: Human rights
treaty bodies and the influence of concluding observations. Glob
Public Health. 2017;13:119.
51. Dresler C, Henry K, Loftus J, Lando H. Assessment of short reports
using a human rights-based approach to tobacco control to the com-
mittee on economic. Cultural Social Rights Tobacco Control. 2018;
52. Committee on the Elimination of Discrimination against Women. List
of issues and questions prior to the submission of the ninth periodic
report of Germany. 11 March 2020.
53. Bueno de Mesquita J. The universal periodic review: A valuable new
procedure for the right to health? Health Hum Rights. 2019;21(2):
54. Action on Smoking and Health. Tobacco control in the United States:
Failure to protect the right to health. Tob Prev Cessat. 2020;6:34.
55. UN General Assembly. Report of the Special Rapporteur on the right
of everyone to the enjoyment of the highest attainable standard of
physical and mental health. UN Doc A/69/299. 11 August 2014.
56. Murphy T, Müller A. The United Nations Special Procedures: Peo-
pling Human Rights, Peopling Global Health. Human Rights in Global
Health: Rights-Based Governance for a Globalizing World. 2018.
How to cite this article: Meier BM, Raw M, Shelley D,
Bostic C, Gupta A, Romeo-Stuppy K, et al. Could international
human rights obligations motivate countries to implement
tobacco cessation support? Addiction. 2022.
While there are legal regulations prohibiting smoking in indoor areas in Turkey, there is none for outdoor areas. Many non-smokers are exposed to environmental tobacco smoking against their will in Turkey. Numerous research efforts have documented the fact that environmental tobacco smoke poses risks to human health because it pollutes the environment by releasing dangerous chemicals into the air that non-smokers breathe. This means that tobacco smoking poses risks to a safe environment and people’s lives. People have a right to the environment, as guaranteed by the Turkish Constitution. Since Stockholm Declaration, many countries have recognized that people have a right to a safe environment or that a safe environment is essential to the enjoyment of human rights, including Turkey. However, how non-smokers perceive of the impacts of environmental tobacco smoke on the enjoyment of the right to the environment enshrined within the Turkish legal system has not been studied to date. Accordingly, this research aims to explore how issues relating to environmental tobacco smoke can be approached from an environmental human rights perspective. To achieve this purpose, a qualitative case study was conducted in Istanbul. The results of this analysis show that non-smokers do not enjoy the right to the clean environment guaranteed by the Turkish Constitution due to the ETS.
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Objective To examine the use of different cessation aids among current South African smokers who have ever tried to quit smoking. Design Cross-sectional design. Setting South Africa has progressively passed several policies over the past few decades to encourage smoking cessation. Data on cessation behaviours are needed to inform policymaking. We investigated utilisation of evidence-based cessation aids and e-cigarettes among current combustible smokers. Current tobacco use, past quit attempts and use of evidence-based cessation aids (counselling, nicotine replacement therapy or prescription medication) were self-reported. Data were weighted and analysed using descriptive and multivariable approaches (p<0.05). Participants Online participants were recruited from the national consumer database for News24—South Africa’s largest digital publisher. Of the 18 208 participants aged 18 years or older, there were 5657 current smokers of any combustible tobacco product (cigarettes, cigars, pipes or roll-your-own cigarettes), including 4309 who had ever attempted to quit during their lifetime. Results Current combustible tobacco smoking prevalence was 22.4% (95% CI: 21.2% to 23.5%), and 98.7% of all current smokers of any combustible tobacco were current cigarette smokers. Awareness of cessation aids was as follows among current combustible tobacco smokers: smoking cessation counselling programmes, 50.8% (95% CI: 48.1% to 53.6%); nicotine replacement therapy, 92.1% (95% CI: 90.5% to 93.6%); prescription cessation medication, 68.2% (95% CI: 65.2% to 70.6%). Awareness of cessation aids was lowest among Black Africans, men, and persons with little or no income. Of all current combustible tobacco smokers, 74.6% (95% CI: 72.2% to 76.7%) had ever attempted to quit and 42.8% (95% CI: 40.0% to 45.4%) of these quit attempters had ever used any cessation aid. Among current combustible smokers who attempted to quit in the past, ever e-cigarette users were more likely than never e-cigarette users to have ever used any cessation aid (50.6% vs 35.9%, p<0.05). Of current combustible smokers intending to quit, 66.7% (95% CI: 64.2% to 68.9%) indicated interest in using a cessation aid for future quitting. By specific aids, 24.7% (95% CI: 21.3% to 28.1%) of those planning to use any cessation aid were interested in getting help from a pharmacist, 44.6% (95% CI: 40.9% to 48.4%) from a doctor, 49.8% (95% CI: 46.0% to 53.6%) from someone who had successfully quit, 30.0% (95% CI: 26.7% to 33.4%) from a family member and 26.5% (95% CI: 23.0% to 30.0%) from web resources. Conclusion Only two in five past quit attempters had ever used counselling/pharmacotherapy. Any putative benefits of e-cigarettes on cessation may be partly attributable to pharmacotherapy/counselling given concurrent use patterns among past quit attempters using e-cigarettes. Comprehensive tobacco control and prevention strategies can help reduce aggregate tobacco consumption.
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Progress in the fight against the tobacco epidemic has been too slow in the WHO European Region. The human rights-based approach provides a novel instrument to advance tobacco control and thereby increase the pace and sustainability of tobacco control policies. This paper discusses how production, marketing and use are associated with human rights violations and how human rights arguments and instruments can be used to advance tobacco control. Human rights – such as those to life and health as well as the rights to safe working conditions, protection from hazardous child labour and the best interest of the child – place obligations on governments and, above all, they give them the right to protect the population from the tobacco industry. They help increase support from other government departments tobacco and the public, can be invoked in court cases to defend tobacco control measures and have an independent monitoring system, unlike the WHO Framework Convention on Tobacco Control. This paper describes advances that have already been made in the European Region and globally.
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Background: Smoking cessation pharmacotherapies (SCPs) have been established as cost-effective for the treatment of tobacco use disorder across a variety of settings. In Jordan, a resource-constrained country where smoking rates rank at one of the highest globally, the cost-effectiveness of SCPs has not yet been quantified. The lack of information about the value of SCPs has contributed to low demand for them (from public and private payers) and consequently low availability of these medications. The aim of this study was to simulate-in a hypothetical cohort of Jordanian smokers-the clinical and economic impact of using two smoking cessation regimens and to generate cost-effectiveness values that can support policy changes to avail smoking cessation medication in a country burdened with heavy tobacco use. Methods: We employed a similar approach to a widely used economic model, the Benefits of Smoking Cessation on Outcomes (BENESCO) model. A hypothetical cohort of Jordanian male smokers aged 30 to 70 years and making a quit attempt using either a varenicline regimen or a nicotine replacement therapy (NRT) regimen were followed over time (until reaching 70 years of age). Markov simulations were run for the cohort, and life years gained were computed for each arm (compared to no intervention). Drug costs, prevalence of smoking, and population life expectancies were based on Jordanian data. Efficacy data were obtained from the literature. Incremental cost-effectiveness ratios as well as the potential budgetary impact of employing these regimens were generated. Several parameters were modified in sensitivity analyses to capture potential challenges unique to Jordan and that could impact the results. Results: For a treatment cohort of 527,118 Jordanian male smokers who intended to quit, 103,970 life years were gained using the varenicline regimen, while 64,030 life years were gained using the NRT regimen (compared to the no-intervention arm of life years). The cost per life year gained was JD1204 ($1696 USD) and JD1342 ($1890 USD) for varenicline and NRT, respectively.
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This chapter analyzes the fundamental importance of monitoring and review procedures to assess the implementation of human rights to advance public health. Recognizing monitoring and review as central to human rights accountability, the evolving functions of human rights monitoring highlight the range of national, regional, and international review mechanisms that provide oversight to support the realization of health-related human rights. While these mechanisms often do not have judicial powers—their recommendations are advisory rather than legally binding—the interpretive role entrusted to these review procedures has endowed their health-related recommendations with legitimacy in clarifying human rights treaty provisions and reviewing state efforts to meet treaty obligations. Assessing the implementation of international human rights law through national practice, monitoring institutions can facilitate human rights accountability for public health promotion and operationalize public health data to press governments to implement rights.
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1. Tobacco is often viewed as a problem that has been solved, particularly in the United States. However, tobacco kills more than 0.48 million Americans per year 1 . About 1 in 5 deaths in the United States is due to tobacco. 2. Tobacco is a human rights issue and should be considered as part of the government’s human rights obligations. Tobacco, and the actions of the tobacco industry, prevents citizens of the United States from enjoying the highest attainable standard of health and disproportionately impacts people of certain races and socioeconomic condition.
The WHO MPOWER package is a set of six evidence-based and cost-effective measures which was introduced on 7 February 2008 to facilitate the implementation of the provisions of the WHO Framework Convention on Tobacco Control at the ground level. These measures are: Monitoring tobacco use and prevention policies (M); Protecting people from tobacco smoke (P); Offering help to quit tobacco use (O); Warning about the dangers of tobacco (W); Enforcing bans on tobacco advertising, promotion and sponsorship (E); and Raising taxes on tobacco (R). Since its launch, the MPOWER package has become the guiding principle for all the countries of the South-East Asia Region in their crusade against the tobacco epidemic. This review article tracks the implementation of the MPOWER measures in the 11 member countries of the Region based on the last seven WHO Report on the Global Tobacco Epidemic (GTCR), i.e., GTCR2/2009-GTCR8/2021. This is with an aim to enable the countries to review their progress in implementing the MPOWER measures and to take steps to improve their advancement towards reducing the demand for tobacco products at the country level.