The Framework Convention on Tobacco Control’s recommendations on price and tax measures: Barriers to implementation in South Africa

1 Introduction

Tobacco use imposes an unparalleled health, economic and social burden worldwide (World Health Organization [WHO] 2015). In 2015, smoking was responsible for more than one in ten deaths globally, killing approximately six million people and inflicting a corresponding loss of nearly 150 million disability-adjusted life-years (Global Burden of Disease 2015 Tobacco Collaborators 2017). Accompanying this burden of death and disease are sizeable economic costs. These accrue directly through medical treatment for tobacco-related diseases, and indirectly through productivity losses from premature mortality and morbidity (US National Cancer Institute [NCI] and WHO 2016). Globally, the total economic cost of smoking, after including productivity losses from death and disability, amounts to more than USD1.4 trillion per year—equivalent in magnitude to 1.8% of the world’s annual GDP (US NCI and WHO 2016). 

Tobacco control is the area of public health which focuses on controlling and reducing tobacco use, thereby limiting and reducing its associated mortality and morbidity. Global best practice in tobacco control policy is anchored by the World Health Organization’s Framework Convention on Tobacco Control (FCTC) (Mitchell & Voon 2014). The FCTC is the world's first global public health treaty, developed with the objective of ‘protect[ing] present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke’ (WHO 2003). 

After four years of negotiation by WHO member states, the treaty was adopted by the World Health Assembly on 21 May 2003 and entered into force on 27 February 2005 (Lariviere et al. 2005). To date, 181 countries have ratified the FCTC (Framework Convention Alliance 2017). Through the treaty text itself and guidelines approved by the Conference of the Parties, which is the decision-making body of the treaty, the FCTC requires ratifying countries to implement a broad range of evidence-based measures to reduce both the demand for (Articles 6-14) and supply of (Articles 15-17) tobacco products. 

As is the case with any international treaty, the crucial ingredient in the success of the FCTC is effective implementation of its provisions by ratifying countries (David & Da Costa e Silva 2004). The evidence base documenting the effectiveness of fully implementing the FCTC’s provisions in reducing tobacco use informed their initial inclusion in the treaty (WHO 2003). Since then—driven by the scholarly literature on tobacco control—the validity of implementing the FCTC’s provisions as a means to reduce tobacco use is increasingly evident (Blecher 2008; Chung-Hall et al. 2016; Chaloupka et al. 2017). 

Despite this, progress in implementing the Convention has been uneven across countries (WHO FCTC Convention Secretariat 2016b). This highlights the importance of understanding local contexts for ensuring full and effective FCTC implementation (Drope 2011; Crosbie et al. 2011; Cairney et al. 2012). Several scholars have, consequently, undertaken country-level case studies of FCTC implementation, in order to identify barriers to implementation, so that a more effective implementation can be achieved (Bai et al. 2015; Hoek et al. 2012; and Tumwine 2011). This research is now more relevant than ever, as strengthening progress in FCTC implementation has been listed as a Sustainable Development Goal (Framework Convention Alliance 2015).

This paper will conduct an analysis of FCTC implementation in South Africa, so that barriers to a full and effective FCTC implementation can be identified. Like many other studies of FCTC implementation, this paper limits its focus to the implementation of one of the FCTC’s articles. Specifically, it focuses on implementation of Article 6 (‘price and tax measures to reduce the demand for tobacco’). This Article was selected because it represents an area in which South Africa had enacted policy measures, reflecting the spirit of the FCTC, prior to the its entry into force at the international level, but in which policy progress has stagnated in recent years.