Progress & Perseverance in the Mission to End Smoking

In 2020, we learned to take nothing for granted. In addition to an incomprehensible loss of life, we also lost comforting rituals, such as going to restaurants, attending concerts, and embracing loved ones. 2021 brought vaccines and, along with them, hope for the restoration of normalcy. Yet, as the world rebuilds, many are recognizing that certain aspects of normalcy may not be worthy of restoration.

In the field of tobacco control, the status quo has utterly failed. Over a billion people still smoke worldwide and more than eight million die each year as a result of this habit—despite decades of organized efforts to curb smoking rates. Given these trends, a return to normalcy is an inadequately ambitious goal. The Foundation for a Smoke-Free World was founded on the belief that tobacco control desperately needs new ideas. Since the Foundation’s inception, we have worked to identify innovative approaches to smoking cessation and harm reduction, with the goal of ending the use of combustible cigarettes worldwide. As our staff grappled with the effects of COVID-19 on both our personal and professional lives, we did not lose sight of this goal. On the contrary, the events of 2020 reinvigorated our commitment to public health and shed new light on systemic failures that contribute to the smoking epidemic.

Indeed, the pandemic brought long-needed attention to chronic challenges in public health. Consider, for example, the slew of politicized misinformation surrounding masks. Despite sound science on the topic, ideological messaging led many to forgo these life-saving measures. A similar phenomenon has taken place in conversations surrounding tobacco harm-reduction products (HRPs). Like masks, these products save lives. Yet, their use has been politicized and their benefits clouded by groups who spread falsehoods to serve an ideological agenda. Both cases highlight the need to identify sources of misinformation and curb their spread.
Of course, the pandemic also inspired public health conversations more substantive than an inane mask “debate.” For one thing, COVID underscored the staggering global rates of noncommunicable diseases (NCDs), including those caused by smoking. In the framework of the pandemic, these came to be known as “underlying conditions”—diseases like lung cancer, diabetes, and heart disease―that render an individual particularly vulnerable to the effects of COVID. Yet, even absent a virus, these conditions represent an enormous health burden and account for the majority of the world’s premature deaths.

It is troubling that lockdown conditions exacerbated behaviors that often underlie NCDs, such as poor diet, lack of exercise, and alcohol and tobacco use. Thus, as we inoculate ourselves against the virus properly, we must redirect resources to the conditions that preceded and will outlast the pandemic. Indeed, ongoing efforts toward pandemic preparedness should entail not just infrastructure to rapidly develop vaccines, but also measures to prevent and manage NCDs. Unfortunately, the pandemic has already usurped funding from some such efforts. This cannot stand.

Finally, the pandemic highlighted dramatic health care inequities. Testing and vaccine distribution failed the most vulnerable populations, including marginalized communities, as well as those living in low- and middle-income countries. Historically, tobacco-control efforts have failed these same populations—an unacceptable gap that the Foundation is working to address.

As we emerge from the pandemic, the Foundation’s goal remains unchanged: we are committed to ending smoking in this generation. Yet, the events of 2020 point to new strategies that may help us achieve this goal. Namely, we must combat misinformation about tobacco and nicotine, redirect resources to the prevention of NCDs, and ensure that these efforts reach the most vulnerable populations. In 2020, we launched and advanced several initiatives that speak to these priorities. For example:

• We conducted a poll investigating how lockdown conditions affected tobacco consumption, mental health, and other factors among smokers and nicotine users in five countries.
• Our staff and partners contributed to a special issue in Drugs and Alcohol Today, which identified shortcomings of tobacco-control orthodoxy. Articles described, among other things, the failure to address smoking rates among women and marginalized communities.
• We released findings from a Global State of Smoking poll, which documented (mis)perceptions about tobacco and nicotine—a first step in reducing false beliefs.
• We sponsored initiatives to better understand HRP misperceptions, including Burning Issues: The Global State of Harm Reduction and the Dubrovnik Consultation Summary.
• We launched the Tobacco Transformation Index, the first tool to rank the world’s 15 largest tobacco companies, which account for nearly 90% of global cigarette volume, on their relative progress toward harm reduction.
• In Malawi, the ATI has made great progress on a number of programs that will help smallholder tobacco farmers transition to alternative livelihoods. This included impactful work within key pillars of the Centre for Agricultural Transformation and the launch of the MwAPATA Institute.

Like most global organizations, the Foundation found that its funding was impacted over the course of 2020. This change accelerated plans to tighten the focus of our research portfolio, which now prioritizes the corroboration of innovative cessation and harm-reduction strategies. This shift also entailed internal restructuring and affected most of our grantees. Although some of these changes were challenging, we ended the year feeling capable and confident in our plans for the future.

2020 taught us that global health systems are critically flawed. COVID did not create these problems. However, it can motivate us to finally solve them.