Japan: Poor enforcement of anti-smoking measures leads to high prevalence and mortality

A study published in the journal Tobacco Control[1] sought to quantify the long-term impact of implementing MPOWER tobacco control measures[2], in line with the WHO Framework Convention on Tobacco Control (FCTC) on smoking prevalence and mortality among men and women aged ≥20 years in Japan. The assessment of the implementation of these measures in Japan highlights the country's shortcomings in this regard. The authors emphasize that the implementation of a comprehensive tobacco control strategy could save up to 240,000 lives by 2050 in Japan.

A simulation model was used to project smoking prevalence and mortality from 2018 to 2050 under eight different scenarios: (1) maintaining the status quo of public policies in force in 2018, (2) implementing measures to ban smoking and protect the population from tobacco exposure, (3) smoking cessation programs, (4) health warnings on packages, (5) media prevention campaigns (6) enforcement of the tobacco advertising ban (7) tobacco taxation at the highest recommended level and (8) all these interventions combined at the best possible level.

Japan's delay in implementing the Framework Convention

Japan ratified the WHO FCTC in June 2004. However, implementation of the treaty's measures has been fragmented, and tobacco control remains far below FCTC good practices. In 2018, Japan received poor scores for complete or minimal policy in the areas of protecting the public from tobacco smoke – smoking bans (measure P), warning about the dangers of tobacco (W), and compliance with the ban on tobacco advertising, promotion, and sponsorship (E).

The Tokyo 2020 Olympic and Paralympic Games have generated social pressure and political will in the area of public health. The tobacco control movement has been somewhat bolstered by the adoption of new policies such as increased tobacco taxes. However, despite these new Olympic-related measures and public demand for denormalization of smoking, progress in tobacco control policy in Japan has been slow compared to countries with similar income levels, particularly Western countries.

For example, cigarette packs remain very affordable in Japan (less than 4.5$ per pack), which applies a lower tax than that recommended by the WHO. According to a study, two-thirds of the Japanese population remains exposed to tobacco advertising and coverage of smoking cessation services is partial, with full cost coverage only available to "heavy smokers" and no national smoking cessation hotline.

A prevalence that remains high among men and increases among women

Japan's slow progress in tobacco control is reflected in the high smoking prevalence among men, at 27.1% in 2019 (compared to 8.6% among women), which was higher than in other high-income countries. Smoking was the leading risk factor for noncommunicable disease (NCD) mortality among Japanese adults, contributing an estimated 19.1% to 24.6% of total deaths among men and 3.6% to 6.1% among women. In 2012, the Ministry of Health, Labour and Welfare set a national target of 12.1% for overall smoking prevalence by 2022. This target will be far from being met, according to the study authors.

The authors add that the study did not consider the potential impact of the growing popularity of heated tobacco products. In Japan, heated tobacco use is growing, particularly among young male smokers, who use them with or without the intention of quitting. While the use of heated tobacco can influence individual smoking habits, its impact on smoking cessation has not yet been demonstrated.

Heavy tobacco industry interference in Japan

Although the public health benefits of strengthening tobacco control measures are clear, Japan faces numerous challenges in implementing tobacco control due to industry interference in policymaking. The main political challenge is the Japanese government's 33% stake in tobacco giant Japan Tobacco. Japan was ranked among the worst countries in 2021. the global tobacco industry interference indexThis index measures government efforts to combat tobacco industry interference. The authors state that it will be easier to strengthen efforts to eliminate smoking in Japan if the government adopts strict regulations regarding tobacco industry interference in health policies and complies with Article 5.3 of the WHO FCTC.

Only the implementation of comprehensive and coordinated policies could lead to a significant reduction in smoking.

Under the researchers' status quo scenario, smoking prevalence is projected to decline steadily from 29.6 % to 15.5 % for men and from 8.3 % to 4.7 % for women between 2018 and 2050.

In the policy-focused scenarios, smoking prevalence would be reduced on average to 14/15% among men and between 4.2 % and 4.5 % among women by 2050. Policies to protect people from tobacco smoke by establishing smoke-free places would achieve the greatest reduction in prevalence.

Unsurprisingly, the reduction in smoking prevalence would be greater and faster when all MPOWER measures are implemented simultaneously, according to current best practices, reducing smoking prevalence to 10.6 % in men and 3.2 % in women by 2050.

If all MPOWER measures were implemented simultaneously at the highest level, the researchers estimate that 237,299 deaths (196,455 men and 40,844 women) would be averted in premature deaths by 2050. This would represent three to eight times more deaths averted than any individual MPOWER policy. The WHO Global Action Plan for the Prevention and Control of NCDs 2013-2020 set a global target of a relative reduction of 30 % in tobacco use prevalence by 2025, using 2010 as a baseline, which means a reduction in tobacco use prevalence from 32.2 % to 22.6 % in men and from 8.4 % to 5.9 % in women in Japan.

Under the business-as-usual scenario, Japan would achieve the international target of a 30 % relative reduction in smoking prevalence among men by 2034 and among women by 2038, and the national target of a 12 % overall smoking prevalence by 2041. With the full implementation of MPOWER, Japan would achieve the international targets for smoking prevalence among men and women in 2028 and 2031 respectively, and the national target for overall smoking prevalence in 2033 instead of 2022. These results demonstrate the need for Japan to guard against tobacco interference and to implement, at the highest possible level, all the provisions of the FCTC that allow for a true denormalization of tobacco consumption.

Keywords: Japan, Framework Convention, FCTC, WHO, prevalence, deaths, smoking, heated tobacco, smoking cessation, MPOWER ©Generation Without Tobacco

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[1] Yang SL, Togawa K, Gilmour S, et alProjecting the impact of implementation of WHO MPOWER measures on smoking prevalence and mortality in JapanTobacco Control Published Online First: 13 September 2022. doi: 10.1136/tc-2022-057262 [2] M: monitor tobacco use and prevention policies; P: protect people from tobacco smoke; O: offer help to quit smoking; W: warn of the dangers of tobacco; E: enforce the ban on tobacco advertising, promotion, and sponsorship; R: increase tobacco taxes. National Committee Against Smoking |