Framework Convention on Tobacco Control (FCTC) Article 14 guidelines: a new era for tobacco dependence treatment
Guidelines on Article 14 (tobacco cessation and treatment) of the World Health Organization (WHO) Framework Convention on Tobacco Control have been adopted by the 172 Parties to the Convention. Thus, for the first time, official policy exists internationally to help countries develop appropriately tailored systems to encourage and help tobacco users to stop. This should accelerate the development of tobacco dependence treatment internationally.
On Friday 19 November 2010, in Punta del Este, Uruguay, the fourth Conference of the Parties (COP4) to the World Health Organization Framework Convention on Tobacco Control (WHO FCTC)  adopted guidelines for the implementation of Article 14 of the Convention. [A COP is a treaty's governing body and provides a vehicle for deciding how United Nations (UN) treaties should be implemented; the FCTC COP meets periodically: in 2010 it met for 1 week and considered guidelines for several Articles and other issues, including treaty finance and governance.] Article 14 asks Parties to develop national guidelines and effective measures to encourage and assist tobacco cessation (see Table 1). This means that for the first time ever a global policy exists, set by a UN treaty, to support countries in developing treatment systems to help those addicted to tobacco to become tobacco free. This editorial examines how this came about and what it might mean for the future of tobacco dependence treatment.
Table 1. Framework Convention on Tobacco Control (FCTC) Article 14: demand reduction measures concerning tobacco dependence and cessation.
|(1)||Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific 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)||Towards this end, each Party shall endeavour to:|
| a.||Design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations 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, preventing and treating tobacco dependence|
| d.||Collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to Article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate|
The FCTC is the only UN treaty on health. It was negotiated under the auspices of the WHO between 1999 and 2003 and entered into force in 2005. It is one of the most widely embraced treaties in UN history and now has 172 Parties, representing 90% of the 192 member states of the UN and 87% of the world's population .
The Convention covers demand and supply side policies. The core demand reduction policies are price and tax measures, protection from exposure to tobacco smoke, product and product contents disclosure regulation, education, advertising restrictions and treatment to aid cessation. The principal supply side policy concerns illicit trade (including smuggling), through the development of a Protocol to the treaty.
Since 2005, guidelines have been adopted and published on several treaty articles. They are intended to help Parties interpret and implement the Articles, particularly as the Articles themselves are short: Article 14 is just two paragraphs covering half a page (Table 1). In South Africa in 2008, COP3 asked for guidelines on Article 14 to be drafted and presented to COP4. Thirty-six Parties (Table 2) volunteered for the working group and two volunteered to lead the drafting. Three Parties joined these two later, so that the leaders were: Ghana, Iran, South Korea, United Kingdom and Uruguay. The guidelines were completed and presented to COP4, which adopted them [3,4].
Table 2. The 36 members of the Article 14 working group.
|Bahrain, Botswana, Brazil, Burkina Faso, Burundi, Canada, Djibouti, European Community, France, Germany, Georgia, Ghana, Greece, India, Iran, Lesotho, Malaysia, Mali, Mexico, Namibia, New Zealand, Nigeria, Republic of Korea, Russian Federation, Saudi Arabia, Singapore, Solomon Islands, South Africa, Syrian Arab Republic, Thailand, Turkey, Uganda, UK, Tanzania, Uruguay, Venezuela|
THE ARTICLE 14 GUIDELINES
The Article 14 guidelines  start with ‘underlying considerations’ and then have three main sections. The underlying considerations acknowledge that that nicotine is highly addictive, and that treatment should be evidence based, accessible and affordable and should be protected from commercial and vested interests. The first main section gives guidance on the development of basic infrastructure for treatment and stresses that as far as possible Parties should use existing infrastructure, partly to keep costs down. The second main section describes the key components of a treatment system, including population approaches that promote cessation and drive demand for treatment, such as mass communications. The third main section recognizes that in many countries treatment is not yet on the agenda [5,6], that it is important to develop treatment in the context of the policies contained in other FCTC articles, which motivate tobacco users to stop and that all countries have finite resources. Thus, the third main section suggests a stepwise approach. It recommends which interventions should be prioritized given limited resources.
SCIENCE AND POLICY
The FCTC is intended to be evidence-based and Article 14 states that national guidelines should also be evidence-based. Article 14 is based on a substantial body of scientific research, published over more than 50 years, including both high-quality randomized trial and real-world observational studies . Many scientists were involved in the writing of the Article 14 guidelines, as members of the official government delegations and as members of observer organizations on the working group. However, most treatment research has been conducted in high income countries. Low and middle income countries seeking to create treatment services will need to interpret the research in the light of their own infrastructure, culture and experience, and the guidelines strongly endorse such an approach. ‘Real-world’ research such as the International Tobacco Control Policy Evaluation Project should continue to assess the effectiveness of different models of treatment in different types of countries and will undoubtedly aid this process . The Article 14 guidelines also stress the importance of health-care workers monitoring services in order to evaluate and improve them continuously.
WHAT DO THE GUIDELINES MEAN FOR THE FUTURE?
Countries wanting to develop tobacco dependence treatment do not have to start from scratch: they now have official policy to guide them. If they follow these guidelines, those that do not yet have treatment systems will focus first on basic infrastructure, including designating an official in charge of treatment and setting a treatment budget, and prioritizing broad reach, lower-cost approaches, especially the systematic provision of brief advice by health-care workers, quitlines and, as soon as possible, access to low-cost medications. This will almost certainly result in some countries now seeking to develop treatment. Parties to the FCTC should recognize more effectively where treatment fits into their overall tobacco control policy, and the ethical case to provide support for those that are motivated to stop but find that they cannot do so unaided.
As always, finding resources will be a challenge, which is why the guidelines emphasize taking advantage of existing infrastructure. Adoption of the guidelines also throws out a challenge to organizations, including the WHO, to scale up their efforts to assist countries; and finally, this new situation challenges scientists and policy advocates to renew efforts to work with governments to develop and monitor effective tobacco dependence treatment systems.
Declaration of interests
In the last 5 years M.R. has had conference expenses reimbursed, been paid an honorarium for a talk and received freelance fees from Pfizer, but has not accepted support from the manufacturers of stop smoking medications in the last 4 years.
The author is grateful for comments on a draft of this paper from Lekan Ayo-Yusuf, Eduardo Bianco, Thomas Glynn, Katie Kemper, Harry Lando, Scott Leischow, Ann McNeill, Hayden McRobbie, Ken Wassum and Gustavo Zabert, and for the referees' helpful feedback. M.R. worked on the drafting of the Article 14 guidelines with financial support from Bloomberg Philanthropies, to whom he is extremely grateful.