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Figure 1 yA++ ddWHOSMALL.WPG| yy22dddy  X,0OO        h![UKUKWHO/PSA/96.5 page   X yz0dddyh! $[   yzldddyXÍ.XÍ.XÍ.Í. #g\  PP#  j  PART A:` (X\\/REPORT ON "\  j7 XXT T X !X(PLAN OF ACTION FOR 19881995#XN\  PƒXP#"   yzX dddy  X Historical background #%G\  P%P# WHO's Constitution and other official WHO documents indicate that WHO's most important roles include coordinating international policies and practices, and providing support to Member States  SX as they strive to improve the health status of their populations.% S   UKUKЍ #%G\  P%P#XConstitution of the World Health Organization, Basic Documents, Fortieth Edition, World Health Organization, Geneva, 1994. The World Health Organization has defined health in a comprehensive manner, stating that:  S  X#%G\  P%P# "#%G\  P%P#Health is a state of complete physical, mental and social wellbeing and not  S merely the absence of disease or infirmity.#%G\  P%P#"#%G\  P %P# % S   UKUKЍ#%G\  P %P#XWorld Health Organization definition of health. Basic Documents, Fortieth Edition, World Health Organization, Geneva, 1994. This definition has special relevance to the challenge of developing effective national tobacco control strategies. Most of the time, smokers are not sick they have "absence of disease". But smokers also face a 50% probability of dying prematurely from a disease caused by their smoking. Neither, then, can they be called "healthy". When health is considered in this its broadest sense, the presence of tobacco use is a clear sign of ill health. The World Health Assembly first formally expressed its concern about the hazards of tobacco use  SN when it adopted resolution WHA23.32, Limitation of Smoking in 1970.% S   UKUKЍ#%G\  P %P#XWHA23.32, Limitation of smoking. The Twentythird World Health Assembly. The World Health Assembly continued to express it's mounting concern about the growing tobacco epidemic by  S( adopting 13 more resolutions on tobacco issues in 1971,% S   UKUKЍ#%G\  P %P#XWHA24.48, Limitation of smoking. The Twentyfourth World Health Assembly. 1976,% S   UKUKЍ#%G\  P %P#XWHA29.55, Control of Smoking. The Twentyninth World Health Assembly.  1978,% S   UKUKЍ#%G\  P%P#XWHA31.56, Control of Smoking. The Thirtyfirst World Health Assembly. 1980,% S   UKUKЍ#%G\  P%P#XWHA33.35, Control of Smoking. The Thirtythird World Health Assembly.  and then at each  S World Health Assembly from 1986 to 1993, and again in 1995.% S   #&`\  P6"&P#UKUKЍXWHA39.14, Tobacco or Health. The Thirtyninth World Health Assembly. WHA40.38, 7 April 1988, A World NoSmoking Day, The Fortieth World Health Assembly. WHA41.25, Action Programme on Tobacco or Health, The Fortyfirst World Health Assembly. WHA42.19, Tobacco or Health, The Fortysecond World Health Assembly. WHA43.16, Tobacco or Health, The Fortythird World Health Assembly. WHA44.26, Smoking and Travel, The Fortyfourth World Health Assembly. WHA45.20, Collaboration within the United Nations System, General Matters, The Fortyfifth World Health Assembly. WHA46.8, Use of Tobacco within the United Nations System buildings, The Fortysixth World Health Assembly. Taken together, these resolutions add up to a clarion call from the World Health Assembly for a comprehensive global approach to stemming the growth of the tobacco pandemic. In 1988, the World Health Assembly called for the DirectorGeneral to develop a tobacco or health (WHA41.25). In 1989, the World Health Assembly  S approved the WHO Programme on Tobacco or Health Plan of Action: 19881995. % S   UKUKЍ#%G\  P%P#XWHO Programme on Tobacco or Health Plan of Action: 1988.1995. A42/7, 9 March 1989. In 1990, the World Health Assembly requested the DirectorGeneral to monitor and report biennially to the Health Assembly on the progress and effectiveness of Member States' comprehensive tobacco  S# control programmes. % S   UKUKЍ#%G\  P%P#XWHA43.16, Tobacco or Health, The Fortythird World Health Assembly. Such reports were made to the Executive Board and then to the World  S$ Health Assembly in 1993X % S   UKUKЍX#%G\  P%P#EB91/12, WHO Programme on Tobacco or Health: Implementation of Resolutions  S WHA42.19, WHA43.16, and WHA45.20: Report by the DirectorGeneral, Executive Board, Ninetyfirst session, 6 November 1992.X and 1995. % S   UKUKЍ#%G\  P%P#XEB95/27, Tobacco or health, Report by the DirectorGeneral. Executive Board, Ninetyfifth session, 24 October 1994.   XG' #XN\  PƒXP#Review of Plan of Action: 19881995 #%G\  P%P# The 1988 Plan of Action proposed objectives, targets, approaches and activities for each of the three programme components. Progress in achieving targets and completing activities will be briefly reviewed. Under the heading of national tobacco control programmes, the following targets were established:  %UKUKWHO/PSA/96.5 page    yz`dddy  9" "XBy 1992, at least 20% of Member States will have developed a national programme for prevention of tobacco use and its reduction, centring on public health information, school education and legislation."/G1G1G1Ԍ    _UKUKWHO/PSA/96.5 page    yz`dddy 9" "XBy 1994, at least 50% of Member States will have developed a national programme for prevention of tobacco use and its reduction" .  9" "XBy 1995, at least 20% of Member States will have shown a decrease of more than 10% in tobacco consumption as compared to 1988." The first of these is an interim measure only, and needs no further discussion. For the second, while there is no universally accepted definition of what a national programme for prevention and reduction of tobacco use would contain, it seems likely that most national programmes, however rudimentary, would contain at least one legislative element. Therefore, the existence of at least one article of tobacco control legislation can be viewed as an indicator of at least some form however minimal, of a national tobacco control programme. In the early 1990's, it was estimated that 91  S countries had some form of national antitobacco legislation, _ S UKUKЍ#%G\  P%P#XRoemer R. Legislative action to combat the world tobacco epidemic, Second edition. p. xi. very close to half of WHO's 190 Member States. For all intents and purposes, this target has been achieved. An earlier analysis of the third target, reductions of more than 10% in tobacco consumption in at least 20% of Member States concluded that this target was well on the way to be exceeded by more  S than 70%.6_ S UKUKЍ#%G\  P%P#XProgress towards the WHO target for reduction in tobacco consumption. From the World  S Health Organization. Tobacco Control: An International Journal, Summer 1994, 3:169, No. 2. 6 However, this observation was tempered by the observations that consumption fell, but at less than the targeted rate in 23 countries, and actually increased in 28 more. Moreover, one of the larger increases in per capita consumption from 1985 to 1992 (20%) took place in the world's largest producer and consumer of cigarettes China. It can be concluded that, while the objective for some reductions in consumption has been achieved, much work remains to be done to achieve the general and rapid declines in tobacco consumption that will be needed to slow the progress of the looming pandemic of tobaccocaused mortality. Targets for the programme component of advocacy and public information were:  9" "XEach year, WHO will coordinate a "World NoTobacco Day"."  9" "XBy 1990, WHO will have developed an advocacy programme aimed at the promotion of a social image in which nonuse of tobacco is the norm." WHO has successfully sponsored World NoTobacco Day every year since 1988. Since 1990, every World NoTobacco Day has focused on a specific theme. The materials produced for World NoTobacco Day, which include an advisory kit, a press kit, a poster and a video, together with celebrations of the Day both by WHO and Member States, and extensive global media coverage, have all combined to result in full achievement of both targets listed under the advocacy and public information programme component. The third programme component, establishment of clearinghouse had one target:  9" "XBy 1990, WHO will have developed a network for information collection, validation and distribution, in support of national, regional and global action against tobacco use." This target had been only partially achieved, but subsequent progress has been made towards its  S) fulfilment._ S UKUKЍX#%G\  P%P#Programme on Substance Abuse Work Plan 1995, WHO/PSA/94.2. p,G1/-h8Ԍ S ԙ$_UKUKWQWHO/PSA/96.5 \page  c"   c"yz`dddyThe WHO Programme on Tobacco or Health Plan of Action: 19881995 also listed an ambitious programme of activities. While many have been completed and others are nearing completion, there are others where little progress has been made. While not all planned activities have been carried out, the Programme has succeeded remarkably  S well in the face of considerable budgetary restraints. It was indicated in the Plan of Action:1988 S 1995 that extrabudgetary funds were available from American, Japanese and Italian sources, and that if more extrabudgetary resources were not forthcoming, "it will not be possible to carry out the  Sq totality of activities described in Section 5". In fact, during the lifespan of the Plan of Action: 1988 Sa 1995 funding from all three sources was used, and all three of these donors have failed to renew their voluntary contributions. For a time, the Programme found itself in very difficult financial circumstances. However, in 1994 and 1995, new voluntary donations have been received from Australia, Canada, the United Kingdom and the United States Office on Smoking and Health, facilitating WHO's tobacco control activities.  X  #XN\  PƒXP#Problem formulation P S UKUKЍX#%G\  P%P#This section is reproduced from an article entitled "Tobacco: the twentieth century's  S epidemic", first published in Tobacco Alert Tobacco costs more than you think: World No S Tobacco Day Advisory Kit 1995. Tobacco or Health, Programme on Substance Abuse, World Health Organization 1995.#%G\  P%P#  S  Tobacco: The twentieth century's epidemic  S  Tobacco is an insidious danger. There is no sudden outbreak of tobaccocaused disease as people start smoking. Instead, the use of tobacco products causes a typically delayed reaction, with approximately 30 to 40 years delay between smoking initiation and smokingattributable deaths. Ultimately, the end result is still as devastating. At present, tobacco products kill about 3 million people a year. This decade, about 30 million people will be killed by tobacco products. In developed countries, where smoking became widespread during the 1940s and 1950s, the catastrophic effect of past smoking trends can now be seen. About 20% of all deaths currently occurring in developed countries are due to tobacco. Unless we reverse current trends, the annual toll will rise to 10 million over the next 30 to 40 years (when the young smokers of today reach middle age), with 70% of those deaths occurring in developing countries. Therefore, a failure to take serious preventive action on tobacco during this decade will result in approximately 100 million people dying unnecessarily and prematurely in the 2020s or 2030s. This number of deaths is more than twice the total of deaths incurred during the Second World War. Recent data have confirmed that the risks of smoking are substantially higher than previously thought. With prolonged smoking, smokers have a death rate about three times higher than nonsmokers at all ages from young adulthood. If, as is likely, much of this excess mortality is directly attributable to tobacco use, then this implies that the risk of a smoker being killed by the use of tobacco products is at least 50%. Therefore, a lifelong smoker is as likely to die as a direct result of tobacco use as from all other potential causes of death combined! Other problems ensue because the negative health consequences of tobacco are not as immediate as with other hazardous substances. The health risks of tobacco are vastly underestimated by the public, and even by many of those who are responsible for protecting and promoting public health. This is a major reason why tobacco products are still widely available, and why lenient tobacco policies have been allowed to occur. Yet the tobacco use is now widely recognized as one of the major public health challenges facing the world as it enters the twentyfirst century. ,G1--88Ԍ J ddx !x( J    X  X` hp x (#%'0*,.8135@8: