Which countries are the best in tobacco control? A quantitative analysis of the MPOWER 2017

The need for implementation of tobacco control programs is undeniable due to hazards from smoking.1 Tobacco use remains the first preventable cause of morbidity and mortality from chronic diseases worldwide, and the rate of morbidity and mortality is rising due to smoking-related diseases.2,3 Therefore, the first and the most important strategy to confront this is the comprehensive implementation of tobacco control programs.4,5 In this regard, the WHO negotiated the Framework Convention on Tobacco Control (FCTC) treaty in 2003 and so far, 181 countries have ratified it.6 In 2008, a package was proposed to be implemented and included six main components, namely: monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn people about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship, and raise taxes on tobacco.7 Global experiences have revealed that implementation of the above-mentioned six strategies can effectively decrease the rate of consumption and resultantly the consequences and complications of tobacco use.8–1011 Some studies showed that this type of analysis may create a challenge between countries to improve their status on tobacco control.12,13 A study in 2015 showed that fifteen countries the highest scores on tobacco control worldwide.14 This study sought to perform a quantitative analysis of the above-mentioned report and track the status of tobacco control programs of different countries and the six WHO regions in this regard to create competition between parties with introducing best parties and may motivate countries as a stimulant to be more active on tobacco control.

The need for implementation of tobacco control programs is undeniable due to hazards from smoking. 1 Tobacco use remains the first preventable cause of morbidity and mortality from chronic diseases worldwide, and the rate of morbidity and mortality is rising due to smoking-related diseases. 2,3Therefore, the first and the most important strategy to confront this is the comprehensive implementation of tobacco control programs. 4,5In this regard, the WHO negotiated the Framework Convention on Tobacco Control (FCTC) treaty in 2003 and so far, 181 countries have ratified it. 6In 2008, a package was proposed to be implemented and included six main components, namely: monitor tobacco use and prevention policies, protect people from tobacco smoke, offer help to quit tobacco use, warn people about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship, and raise taxes on tobacco. 7Global experiences have revealed that implementation of the above-mentioned six strategies can effectively decrease the rate of consumption and resultantly the consequences and complications of tobacco use.  Some udies showed that this type of analysis may create a challenge between countries to improve their status on tobacco control. 12,13A study in 2015 showed that fifteen countries the highest scores on tobacco control worldwide. 14is study sought to perform a quantitative analysis of the above-mentioned report and track the status of tobacco control programs of different countries and the six WHO regions in this regard to create competition between parties with introducing best parties and may motivate countries as a stimulant to be more active on tobacco control.

METHODS
This cross-sectional study was conducted in the second half of 2017 using a researcher-made checklist that was validated in previous two studies. 13,14The data for each country related to 10 variables were completed and recorded including 7 MPOWER recommendations, 2 compliances, and the prevalence of tobacco use based on the WHO 2017 report.For the 5-item variables, the score was from 0 to 4; and for the 4-item variables, the score was 0-3.Thus, the range of total scores was calculated from zero to 37. The checklist was crossed-check and finalized by the panel of experts at a meeting in Tobacco Prevention and Control Research Center and the scores were confirmed and approved.The scores of each country were finalized and arranged according to the six zones of the WHO in separate tables.
The checklist and the scoring system used are presented in Table 1.

RESULTS
Countries which had at least 85% of total score (32 out of 37) were Seychelles and Mauritius at 33 each (i.e. two from 47 countries, representing 4.2% of the WHO Regional Office for Africa (AFRO) region), Costa Rica 36, Brazil and Panama 35, Surinam and Colombia 34, Canada, Uruguay and Argentina 33 (ie.8 from 35 countries, representing 22.8% of the WHO Regional Office for the Americas AMRO region), United Kingdom and Turkey 36, Portugal, Russia, Ireland 33, Romania, Estonia Denmark, Spain and Norway 32 (ie. 10 from 53 countries, representing 18.8% of the WHO Regional Office for Europe (EURO) region), Iran 34 (i.e. 1 from 22 countries, representing 4.5% of the WHO Regional Office of the Eastern Mediterrean (EMRO) region), and Australia 35, New Zealand 34 (2 from 27 countries, representing 7.4% of the WHO Western Pacific Regional Office (WPRO) region).There was no country in the WHO South East Asia Regional Office (SEARO) region.The 23 countries and their scores (based on the 10 indicators) with differences from 2015 are show in Table 2.
This finding mentioned that Africa region which had fewer countries in top scores (4%) had highest countries in low scores (21%) and it showed vice versa for European region (19%-2%).

DISCUSSION
This study showed that none of the countries had full scores in the tobacco control programs; however, 23 countries (Seychelles, Mauritius, Costa Rica, Brazil, Panama, Surinam, Colombia, Canada, Uruguay, Argentina, United Kingdom, Turkey, Portugal, Russia, Ireland, Romania, Estonia, Denmark, Spain, Norway, Iran, Australia and New Zealand) had a superior status according to the 2017 MPOWER report.These 23 countries may present a best model for other parties in the implementation and enforcement of tobacco control programs.Comparison of scores of different countries in this respect can be beneficial since it creates a challenge for the health policy makers to find weakness of the tobacco control programs to work on it.Also, Europe had a superior position over others as well.
In 2015, fifteen countries, which acquired the highest scores (85% of total 37) included Panama and Turkey with 35, Brazil and Uruguay with 34, Ireland, United Kingdom, Iran, Brunei, Argentina and Costa Rica with 33 and Australia, Nepal, Thailand, Canada and Mauritius with 32 points. 14The comparison between these two studies shows that 4 countries (Brunei, Nepal, Thailand and Mauritius) left and 12 new countries are added to this group.It may a create competition between countries to have more focus on tobacco control.
In pages 136 to 149 of the 2017 MPOWER report 11 we found 9 countries with lowest smoking prevalence in the world, 5% or less including Ethiopia, Ghana and Panama (3%), Ecuador (4%), Benin, Barbados, Eritrea, Niger and Nigeria (5%) and based on Table 3  It might be due to other reasons which can be explored in future studies, but we found a significant negative correlation between low smoking prevalence and high total score.
Since the scores were very much close and most countries had a one-point difference, more precise implementation of each strategy and publishing a more thorough report may change the scores and consequently the ranking of countries in this respect. [Tables show that all of the regions had higher total scores compared with 2015 including Africa +52, America +59, SEAR +35, Europe +109, EMR +43 and WEPR +43.Highest mean score of this is belonging to SEAR with 3.18 and then 2.05 for Europe.It is notable that SEAR has no country in the top 23 but it has best improvement regionally.Also Table 3 to Table 8 show that highest score improvement belong to Timor Leste +13, Cambodia +12, Elsalvador and Romania +9, Uganda, Ruanda, Syrian Arab Republic +8 and highest reduction belong to Cameron -7, Luxemburg -6, San Marino, Libya, Swaziland -5.
The superior position of European countries in this regard has also been mentioned in a study by Joossens. 15Except in the Eastern Mediterranean region, no such a study has been conducted in other parts of the world 16 ; therefore, this can be an interesting research topic for future studies and the results can be used to create a challenge and a competition among countries in an effort to gain a better ranking.

LIMITATIONS
Firstly, the study was limited by not randomizing selection.In addition, we did not ensure the report on MPOWER which was sent from country to WHO was aligned with the real status of tobacco control in the society.

CONCLUSION
Countries perform differently with regard to tobacco control programs and these 23 countries possibly present the best model.

Monitoring: prevalence data
No known data or no recent data or data that is not both recent and representative Recent and representative data for either adults or youth Recent and representative data for both adults and youth Recent, representative and periodic data for both adults and youth

Data not reported
Up to two public places completely smoke-free Three to five public places completely smoke-free Six and seven public places completely smoke-free All public places completely smoke-free

Cessation program
Data not reported None NRT and/or some cessation services (neither cost-covered) NRT and/or some cessation services (at least one of which is cost-covered) National quit line, and both NRT and some cessation services cost-covered

Data no reported
No warnings or small warnings Medium size warnings missing some appropriate characteristics

Data not reported
No campaign conducted Campaign conducted with 1-4 appropriate characteristics Campaign conducted with 5-6 appropriate characteristics

Ban on national television, radio and print media
Ban on all forms of direct and indirect advertising

Taxation
Data not reported ≤25% of retail price is tax 26-50% of retail price is tax 51-75% of retail price is tax >75% of retail price is tax this respect can be beneficial since it creates a challenge for the countries to achieve a higher rank.Based on WHO documents we have a simple validated view of ranking of countries and regions regarding tobacco control which may create a challenge to improve this status.Comparison of scores of different countries in this respect can be motivate the health policy makers to find weakness of the tobacco control programs to work on it.

Compliance bans on advertising
Which countries are the best in tobacco control?A quantitative analysis of the MPOWER 2017 Journal of Global Health Reports Score Complete compliance (8/10 to 10/10) Moderate compliance (3/10 to 7/10) Minimal compliance (0/10 to 2 to Table 8 the total score of those are 22, 22, 35, 31, 26, 23, 18, 23 and 19, respectively.It shows that among these, only Panama is in top 23.

Table 1 . MPOWER WHO score on tobacco control check list based on WHO report 2017 Score Adult daily smoking prevalence
Comparison of scores of different countries inWhich countries are the best in tobacco control?A quantitative analysis of the MPOWER 2017

Table 3 . Africa Region countries ranked by total MPOWER WHO score on tobacco control in 2017*
Which countries are the best in tobacco control?A quantitative analysis of the MPOWER 2017 The mean score of the region=17.40.Which countries are the best in tobacco control?A quantitative analysis of the MPOWER 2017Journal of Global Health Reports *