From the outset, the Ottawa Charter recognised that achieving ‘Health for All’ would require more than aspiration: it would require sustained advocacy, especially given what World Health Organization director-general Margaret Chan described at the time as “formidable opposition” from harmful corporate interests.
In the four decades since, public health advocacy has become more visible and more explicitly recognised internationally, nationally and at community levels, informed by experience with tobacco, alcohol, ultra-processed foods and gambling. The tobacco experience has revealed there are no simple magic bullets: specific measures for which we advocate will not solve the problem overnight, but should be seen as part of a comprehensive approach, to be implemented and maintained over time.
We have also learned that any approaches likely to be effective, especially evidence-based legislation and strong public education, will be fiercely opposed by harmful industries (the ‘scream test’), who will instead support and lobby for measures guaranteed to have minimal impact such as voluntary codes, partial or watered-down restrictions on advertising and promotion, and industry-run education programmes – which pass the ‘smile test’ of industry approval.
Progress and persistent opposition
Given the magnitude of the harms and the opposition’s persistence and resources, it is sometimes hard to recognise the benefits that have resulted from public health advocacy. Tobacco use and exposure still cause more than seven million deaths globally, and tobacco companies and their allies do all they can to maintain and even increase their sales of tobacco and nicotine products. Nonetheless, there has been a global ‘epidemic’ of legislation on advertising bans, health warnings and plain packaging. The WHO Framework Convention on Tobacco Control now has 183 parties and specifies that tobacco control policies should be protected from industry influence. In April 2026 the United Kingdom enacted legislation prohibiting tobacco sales to people born after 31 December 2008. Crucially, smoking has declined dramatically in many countries. Among Australians aged over 14, daily smoking is now down to 5.6% compared to the 1960s, when 58% of males and 26% of females smoked.
Although it takes time for many of the health benefits to become evident, we can be confident that around the world tobacco control advocacy has prevented millions of premature deaths, as well as reducing cost pressures on ever-pressed health systems.
An under-resourced response
But advocacy is grossly understaffed and under-resourced. Predatory industries pour ever-increasing resources into lobbying, public relations and political engagement. In contrast, health advocacy is left to a few organisations with limited resources and many other functions and pressures; community- based advocates with little access to support; researchers for whom advocacy is an add-on to their daily roles; and government employees whose advocacy roles are inevitably constrained. As the profile of public health advocacy has increased in recent decades, it has also led to more harmful industry counter-lobbying and public relations activity, including personal attacks on prominent public health advocates.
The Ottawa Charter had it right in recognising that creating health requires action on the forces that shape the conditions of everyday life. Four decades of experience have reinforced that insight. The challenge now is to build on what has been learned and give advocacy a much stronger place within mainstream public health, with strengthened focus on the systems that produce inequity, including colonisation and racism, and on resourcing Indigenous Peoples and affected communities to lead change on their own terms.
Advocacy is crucial to addressing some of the most pressing health concerns, but it cannot continue to depend disproportionately on a small number of organisations, committed individuals and researchers fitting this work around other responsibilities. It requires investment, infrastructure, training, coordination, evaluation and institutional support. There needs to be more. Governments should learn from the governance principle embodied in the FCTC and develop sector-appropriate safeguards for other harmful industries. Advocates need support and, in turn, advocacy needs to be entrenched as a core duty for mainstream public health.
Ten lessons from tobacco control advocacy
Here are some key lessons learned from decades of advocacy across tobacco control and other commercial determinants of health.
Ensure a consistent focus on the best available evidence about both the magnitude of the problem and the policies that will make a difference.
There are no magic bullets. Individual measures are important but lasting change requires comprehensive approaches sustained over time.
Build broad support among affected communities, health agencies and leaders. Work through disagreements respectfully, lest they be leveraged by those seeking to prevent progress.
Identify, oppose and expose harmful industries. Keep shining a light on the companies, practices and systems that create and profit from harm.
Learn about the way harmful industries operate. Understand their strategies, arguments and tactics. Remember the scream test and the smile test. And beware ‘zombie arguments’ – industry approaches killed off in one country or for one industry, but brought back to life elsewhere.
Protect public health policymaking from the vested interests of industries whose profits depend on products and practices that cause harm. Governments should learn from this governance principle and develop sector-appropriate safeguards for other harmful industries.
Look for innovative approaches to demonstrate the extent of the problem and the case for action – and reuse approaches that have been successful in the past.
Stay with it! Industry takes the long view. Public health advocacy must do the same despite setbacks, delays and personal attacks.
Ensure that credit goes to all who contribute to progress, from affected communities and advocates to practitioners, researchers, communicators, public servants and political decision-makers.
Celebrate success! Change takes time, but sustained tobacco control advocacy has already prevented millions of premature deaths. Recognising and celebrating progress such as this helps to support further advocacy in both tobacco control and other aspects of health promotion.
