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Impact of the WHO Framework Convention on Tobacco Control on global cigarette consumption: quasi-experimental evaluations using interrupted time series analysis and in-sample forecast event modelling

BMJ 2019; 365 doi: (Published 19 June 2019) Cite this as: BMJ 2019;365:l2287

Linked Editorial

Tobacco control: new resources, existing treaties, and emerging challenges

  1. Steven J Hoffman, professor1 2 3 4,
  2. Mathieu J P Poirier, assistant professor1 3 5,
  3. Susan Rogers Van Katwyk, managing research fellow1 4,
  4. Prativa Baral, research fellow1,
  5. Lathika Sritharan, research manager1
  1. 1Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, 4700 Keele Street, Dahdaleh Building 2120, Toronto, Ontario, M3J 1P3 Canada
  2. 2Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
  3. 3Department of Health Research Methods, Evidence, and Impact and McMaster Health Forum, McMaster University, Hamilton, Canada
  4. 4School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
  5. 5School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
  1. Correspondence to: S J Hoffman steven.hoffman{at} (or @shoffmania on Twitter)
  • Accepted 13 May 2019


Objective To evaluate the impact of the WHO Framework Convention on Tobacco Control (FCTC) on global cigarette consumption.

Design Two quasi-experimental impact evaluations, using interrupted time series analysis (ITS) and in-sample forecast event modelling.

Setting and population 71 countries for which verified national estimates of cigarette consumption from 1970 to 2015 were available, representing over 95% of the world’s cigarette consumption and 85% of the world’s population.

Main outcome measures The FCTC is an international treaty adopted in 2003 that aims to reduce harmful tobacco consumption and is legally binding on the 181 countries that have ratified it. Main outcomes were annual national estimates of cigarette consumption per adult from 71 countries since 1970, allowing global, regional, and country comparisons of consumption levels and trends before and after 2003, with counterfactual control groups modelled using pre-intervention linear time trends (for ITS) and in-sample forecasts (for event modelling).

Results No significant change was found in the rate at which global cigarette consumption had been decreasing after the FCTC’s adoption in 2003, using either ITS or event modelling. Results were robust after realigning data to the year FCTC negotiations commenced (1999), or to the year when the FCTC first became legally binding in each country. By contrast to global consumption, high income and European countries showed a decrease in annual consumption by over 1000 cigarettes per adult after 2003, whereas low and middle income and Asian countries showed an increased annual consumption by over 500 cigarettes per adult when compared with a counterfactual event model.

Conclusions This study finds no evidence to indicate that global progress in reducing cigarette consumption has been accelerated by the FCTC treaty mechanism. This null finding, combined with regional differences, should caution against complacency in the global tobacco control community, motivate greater implementation of proven tobacco control policies, encourage assertive responses to tobacco industry activities, and inform the design of more effective health treaties.


  • Contributors: SJH conceived the study, led its design as principal investigator, and supervised implementation. MJPP led the statistical analysis. All authors contributed to the study’s analysis and the preparation and writing of this manuscript, including reviewing, editing, and approving the final manuscript. SJH and MJPP are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This research was supported by the Canadian Institutes of Health Research (project 312902) and the International Collaboration for Capitalizing on Cost-Effective and Life-Saving Commodities (i4C) that is funded through the Research Council of Norway’s Global Health and Vaccination Programme (project 234608). SJH is also funded by the Ontario Government’s Ministry of Research, Innovation and Science. Funders had no influence on the study design; on the collection, analysis, and interpretation of data; on the writing of the report; or on the decision to submit the article for publication. All authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the Canadian Institutes of Health Research (project 312902) and the Research Council of Norway; SJH was previously employed by WHO; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by McMaster University’s Hamilton integrated research ethics board (14-378). We attest that we have obtained appropriate permissions and paid any required fees for use of copyright protected materials.

  • Data sharing: The full dataset used in this study can be accessed at: Additional data, methodological details, and code can be found in the appendices. All enquiries regarding the dataset and analyses can be made to the corresponding author.

  • The lead author (SJH) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned have been explained.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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