Role of World Health Organization Framework Convention on Tobacco Control Global Knowledge Hub on Smokeless Tobacco.

Smokeless tobacco (SLT) is a recognized public health challenge, having over 350 million users globally, concentrated particularly in South-East Asia. A need for research on curbing major challenges in regulating SLT use has been long felt and subsequently highlighted in several sessions of the Conference of Parties (COP) of the Framework Convention on Tobacco Control (FCTC). The sixth session of COP established a knowledge hub on SLT at the Indian Council of Medical Research- National Institute of Cancer Prevention and Research India, with a mandate to (i) generate and share expertise, information and knowledge; (ii) promote and facilitate communication among Parties, organizations and stakeholders; and (iii) support the Convention Secretariat in contributing to technical aspects of SLT control. The hub disseminates scientific evidence through an interactive website and publications and supports national and international partners in SLT research. The hub is a contributor to many events/conferences and has conducted several workshops on SLT control, including an inter-country meeting on SLT policy implementation status, which brought together representatives from across the globe, and framed recommendations for policy reform. The hub is dedicated to interaction and collaboration with relevant tobacco control organizations to generate evidence, support and policy orientation in line with its mandates and recommendations under the World Health Organization FCTC.

Introduction

Smokeless tobacco (SLT), by definition, is a tobacco that is consumed in un-burnt form, either orally or nasally1, and is commonly known as chewing tobacco, oral tobacco, spit or spitting tobacco, dip, chew or snuff2. SLT use has now been recognized as a major public health challenge, with >350 million users in over 130 countries3. SLT constitutes a plethora of unregulated, under-researched and unidentified products; it has been regarded as a growing socio-economic and health concern in many countries of South-East Asia, Eastern Mediterranean and Western Pacific Regions of World Health Organization (WHO)3.

The Framework Convention on Tobacco Control (FCTC)

The Framework Convention on Tobacco Control (FCTC) is the first international treaty under the auspices of WHO dedicated solely to tobacco control (in force since 2005)4. Under its preamble, Parties (member countries ratifying the treaty) agree to a set of guidelines summarized under different articles of the Convention covering various demand and supply reduction aspects of tobacco control. The first chapter, or Article 1 under WHO FCTC, pertains to ‘Use of Terms’ for the purpose of the Convention, wherein clause ‘f’ defines the term ‘tobacco products’ as ‘products entirely or partly made of the leaf tobacco as raw material, which are manufactured to be used for smoking, sucking, chewing or snuffing’4. This definition entails smokeless forms of tobacco as a part of ‘tobacco products’, thereby requiring implementation of all its provisions to both smoke and smokeless forms equally.

Conference of Parties (COP)

Each Party needs to submit biennial reports on the status of implementation of the Convention to the Conference of the Parties (COP) through the Convention Secretariat. Regular sessions of the COP are held every two years5. The first session was held in Geneva in 2006, adopting the rules of procedure of the COP6. Further sessions highlighted the status of adoption of guidelines by every Party and provided recommendations for other concerns.

Fourth session of Conference of Parties (COP)

Although identified earlier, it was the fourth session of the COP (in 2010) where the Convention Secretariat presented a report on the control and prevention of SLT products and recognized SLT use as a global concern1. The session recommended framing specific strategies that can target issues related to SLT. Parties were called upon to work towards developing an integrated tobacco-control programme as part of their ongoing programmes and initiatives. Need for further research on curbing major challenges in regulating SLT use was also highlighted.

Fifth session of Conference of Parties (COP)

The fifth session of the COP, in addition to reviewing global progress on implementation of the WHO FCTC, suggested strengthening of the treaty instruments and requested WHO to carry out further technical work in relation to SLT7. The Convention Secretariat report compiled information on prevalence, product diversity, constituents, health conditions, economics, environmental aspects and experience of the parties to the convention with respect to SLT control8.

The need for a knowledge base, supportive evidence and increased capacity for research in the areas of SLT use, prevention and control was felt. Available research on SLT in general was considered to be limited, with significant research gaps. A need was felt to develop regional and international cooperation mechanisms to identify best practices and promotion of strategies to prevent and control SLT use. Parties facing challenges related to SLT were also required to support in building capacity to formulate SLT-specific policies and their implementation.

Sixth session of Conference of Parties (COP)

In response to the request of the fifth session of COP to enhance international cooperation to strengthen implementation of WHO FCTC, the Convention Secretariat proposed to establish knowledge hubs to facilitate sharing of expertise and knowledge among the Parties to the Convention and development partners as well as other stakeholders9. These knowledge hubs were instituted to act as catalysts for information sharing and building capacity in their respective areas of expertise, in coordination with the entities involved. These knowledge hubs were established based on the guidance of COP to involve all relevant stakeholders (including civil society observer organizations).

Establishing the Global Knowledge Hub on Smokeless Tobacco (SLT-KH)

The sixth session of the COP emphasized the importance of generating evidence and recommending policy reforms at country-specific levels for SLT control9. Consequently, Parties felt the need to establish a dedicated knowledge hub to support work on prevention and control of SLT.

For this purpose, the Convention Secretariat and Ministry of Health and Family Welfare, Government of India, designated the ICMR-National Institute of Cancer Prevention and Research (NICPR) to serve as the WHO FCTC Global Knowledge Hub on SLT (SLT-KH) (hereinafter referred to as ‘Hub’)10. The NICPR is an established institute in the field of cancer surveillance and epidemiological research with key focus on tobacco as a risk factor11. A formal launch of the Hub took place on April 6, 2016 at the Institute and was attended by officials from the Government of India, the WHO FCTC Secretariat, WHO and other stakeholders.

Seventh session of Conference of Parties (COP)

The seventh session of COP, held in India (November 7-12, 2016), recognized and welcomed the establishment of the Hub as a global repository of knowledge and adjudged it as a landmark development in the field of SLT control12.

Roles and responsibilities of the hub

The primary responsibility of the hub is to analyze, synthesize and disseminate knowledge and information relating to SLT control, in accordance with the Article 22 of the Convention4 (Cooperation in the scientific, technical and legal fields and provision of related expertise).

Mandate

The specified mandate of the Hub includes:

Generating and sharing expertise, information and knowledge and providing training pertaining to SLT control as appropriate, regionally and globally;

Promoting and facilitating, as appropriate, communication among the Parties (e.g. WHO FCTC focal points), observers to the COP, including inter-governmental organizations (IGOs), non-governmental organizations (NGOs) and other interested partners; and

Supporting the Convention Secretariat in hosting meetings, preparing technical materials and contributing to technical and subsidiary body meetings as appropriate.

While carrying out its functions, the Hub works in collaboration with various national and international stakeholders, NGOs, as well as partners of the Convention Secretariat13.

Consultation and delegation of work

As a part of the mandate, the Hub responds to and provides support to technical requests from Parties in consultation and coordination with the Convention Secretariat. For this purpose, the Hub utilizes information provided in reports or implementation database of the WHO FCTC.

Collaboration with other knowledge hubs and stakeholders

As of December 2017, seven knowledge hubs under various institutes on significant issues of tobacco control have been established (Figure). The Hub on SLT utilizes various platforms to exchange knowledge, information and experience among other Hubs with support from the Convention Secretariat. The idea is to contribute to promote WHO FCTC-related communication to relevant Parties and/or stakeholders, to advance the implementation of the WHO FCTC provisions globally.

Figure

Global Knowledge Hubs under Framework Convention on Tobacco Control (FCTC) Convention Secretariat.

Dissemination of Work by the Hub

Website

A centralized platform with uniform web design has been developed for all knowledge hubs under , with a URL for Hub on SLT13. The hub disseminates gathered information primarily, although not exclusively, through this interactive portal, which is synchronized with the WHO FCTC Information Platform. As a general principle, all the material published on the website is freely accessible and public. The website provides information on scientific evidence on SLT use in terms of epidemiology, products, chemical profiling, manufacturing, economics, advertising and marketing of SLT. The website also provides information on the Hub partners, both national and international, as well as updates on SLT control activities across the globe. The website also mentions key events and factsheets on SLT-specific information.

Research publications

Since inception, the Hub has published several research papers on SLT-relevant issues such as epidemiology1415, burden of disease and mortality1617, risk factor trends18 and among vulnerable populations19. Current foci of research include estimating burden of disease, cessation, meta-analysis of risk factors, evaluation of global SLT policies as per various articles of the Convention and creation of chemical database relevant to SLT products.

Hub as a contributor to global events on tobacco control

Events

The hub has been a contributor/participant to many events and conferences on tobacco control. The hub participated at the seventh session of the COP, where a monograph on ‘SLT and Public Health in India’ was released20, providing a comprehensive overview of the public health burden of SLT use in India.

World No Tobacco Day, 2017: The Hub commemorated the World No Tobacco Day (WNTD) 2017 and contributed through public awareness initiatives and cancer screening camps21.

Second Global Adult Tobacco Survey (GATS 2, Results), India: On June 8, 2017, the results from the Second Global Adult Tobacco Survey (GATS 2) of India were released22. The GATS 2 reported a reduction in SLT users from 25.9 to 21.4 per cent. Other notable national and international contributions include participation at the 3rd International Conference on Waterpipe Tobacco Smoking Research: Moving towards Action held at the American University of Beirut, Lebanon23; the First World NCD Congress, 2017, Chandigarh, India24; 1st National Conference on Addiction Psychiatry, AIIMS, New Delhi, India25; the 48th Union World Conference on Lung Health, Guadalajara, Mexico26; the 2017 National Conference on Tobacco or Health, Texas, USA27; the 2017 South-south and Triangular Cooperation meeting, Montevideo, Uruguay28; the 2017 Expert meeting on Tobacco Surveillance (Article 20 of WHO FCTC), Helsinki, Finland29.

Workshops/meetings conducted

Work plan of Global Knowledge Hub on Smokeless Tobacco (SLT-KH)

On November 14, 2016, a meeting with representatives from WHO FCTC Secretariat, the SLT-KH, WHO Regional Office for South-east Asia, and National Cancer Institute, USA was held in NICPR, reviewing ways of advancing the work plan of the Hub30.

Workshop on Tobacco Control and Health Informatics (March 29-30, 2017)

The Hub hosted this workshop with an objective to ascertain various aspects of tobacco control with special focus on SLT. The workshop discussed and reviewed recent developments on research activities; updated on national and international initiatives and propagated the role of bioinformatics in SLT research31.

Inter-country meeting on SLT control policy (August 16-18, 2017)

In accordance with the work plan adopted by the sixth session of the COP, the Hub prepared a report reviewing SLT policies across FCTC Parties. The Hub, along with the Secretariat of the WHO FCTC and the WHO Regional Office for South-East Asia, organized an inter-country meeting32 to discuss the findings of the report.

The meeting brought together Party representatives from within and outside the region, as well as subject experts from international agencies, to discuss policy options for prevention and control of SLT products. The outcomes including participants’ key observations about the global SLT policy scenario and their proposals on the way forward to address the identified challenges have been disseminated on the Hub's website33. These are meant to inform the work of Parties to the Convention, of states non-parties and other interested stakeholders on policies to prevent and control SLT use and to also inform future agenda of the COP, as well as other international efforts.

Workshop on Priorities in SLT control - Research & training needs (November 27-28, 2017)

This workshop was conducted with an objective of facilitating exclusive discussion among experts on SLT policy, and its potential global and national impact. The workshop highlighted the challenges faced in SLT research and identified the training needs for the wide spectrum of stakeholders engaged in SLT control in the country34.

Smokeless tobacco (SLT) hub in media

The hub has been widely cited by national and international media, both in print and electronic format, appreciating the activities of the hub in creating awareness on harms of SLT use353637383940. Pertinent issues have been enunciated and published for local, regional and international audience.

The way forward

The SLT-KH works on an important aspect of tobacco control and presents a platform for global stakeholders, Party representatives and policymakers to gather information, obtain and generate evidence pertaining to SLT use and control. The hub embodies a global stand against smokeless forms of tobacco. Research on cigarettes has led to global awareness and regulatory activities on smoking, leading to a gradual shift of tobacco industry's focus on under-researched forms of tobacco, including SLT. This has made SLT control even more significant than ever before. The mandate of the Hub provides an opportunity for further SLT research, and support Parties and concerned organizations. The hub is dedicated to interaction and collaboration with relevant tobacco control advisers/organizations to the extent possible, to assure harmonization, generate evidence, capacity building, research dissemination and policy orientation in line with its mandates and recommendations under the WHO FCTC.