Global solidarity against globalized tobacco: The world's first modern health treaty tackles tobacco
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* Atul Kapur

The world's ministers of health are poised to approve the first global public health treaty — the Framework Convention on Tobacco Control ([http://tobacco.who.int](http://tobacco.who.int)) — at the World Health Assembly in Geneva on May 19–28.1 They hope that, after more than 50 years of such gatherings, a new era of global health protection will be ushered in.

The approval of this treaty will come after almost 10 years of preparations and 4 years of active negotiations.2 A tobacco treaty was first proposed by resolution at the 1994 World Conference on Tobacco or Health,3 but it was not until Dr. Gro Harlem Brundtland became Director-General of the World Health Organization (WHO), in July 1998, that negotiations began in earnest. Six rounds of official negotiations involving delegates from over 170 countries and dozens of nongovernmental organizations (NGOs) ended in February 2003 with the adoption of a draft treaty.4 This treaty was welcomed by Canadian health agencies as an important first step in global health law, and as a significant step toward reducing tobacco use.5

It is not surprising that WHO chose tobacco as the focus for its first treaty effort. Tobacco is not only a global problem, it is a problem of globalization. The vectors of globalization — trade liberalization, direct foreign investment, privatization and diminished role of government — have contributed to the spread of tobacco use by aiding the penetration of Western-style cigarettes into parts of the world where tobacco use had previously been relatively contained. Tobacco use has declined markedly in Canada and some other northern countries,6 but it has grown enormously in the developing world. This year smoking will cause almost 5 million deaths (half in rich countries, half in poor); within 20 years the number will have doubled, and most of those deaths will be in the developing world.7

The tobacco treaty is an attempt to both strengthen and broaden public health measures to reduce smoking. Canada is among many countries that have adopted “comprehensive measures” aimed at reducing tobacco use, including increasing product pricing through taxation, restricting advertising, placing restrictions on where smoking can occur, educating the public, and implementing practice guidelines for clinicians to identify, counsel and monitor patients who smoke (e.g., Ask, Advise, Assist).8 The draft treaty includes all of these measures, as well as those intended to address international or transboundary concerns, such as smuggling and cross-border advertising. Countries that ratify the treaty will undertake to fund tobacco control programs, ban or restrict tobacco advertising, protect workers and the public from secondhand smoke and require large health warnings on tobacco products. The draft treaty contains other measures to encourage governments to keep cigarette taxes high and to hold tobacco companies accountable for the damages they have inflicted.4

As is often the case with social treaties, many of the provisions of the tobacco treaty are general and hortatory, and the sanctions are vague. The weakness of this wiggle-room approach is that little is demanded of an unambitious government. The strength of such flexibility is that it allows countries at varied stages of capacity or readiness to go forward at different rates, even as they collaborate on shared global concerns. The NGO community that closely monitored this treaty's development concluded that the treaty “provides the basic tools for countries to enact comprehensive tobacco control legislation.”9

Different (and occasionally opposing) national approaches were evident during the negotiations. For many developing countries, the treaty was seen as a way for health ministries to overcome indifference or tobacco industry lobbying within their own governments. Through the relatively simple expedient of ratifying the treaty, they hoped to import and implement a comprehensive set of effective measures. These negotiators were looking for very strong and unambiguous treaty requirements.10 Some other countries wanted to sign the treaty but were not yet prepared to make any changes to their domestic policies. They were looking for a treaty that went no further than their current law. A tiny minority of countries (principally the United States)11 consistently proposed weak — even harmful — measures and opposed strong ones.

The draft text that was finally approved was weaker than desired by some regions (notably African countries) but stronger than many expected. The main sticking points were lack of unanimity on requirements for a total ban on tobacco advertising and conflicting views on whether the tobacco treaty should take precedence over or be subordinate to commercial agreements negotiated at the World Trade Organization (WTO).12 There are many ways that public health rules and international trade rules concerning tobacco could come into conflict. For example, a country, for public health reasons, could decide that the allure of packaging should be reduced and require that tobacco products be sold in plain packaging. But this sound public health measure could run afoul of regional and global trade agreements, where it may well be interpreted as a non-tariff trade barrier — a disguised restriction on free trade or a prohibited restriction on the use of trademark, or both.

The compromises reached (advertising bans for countries that faced no constitutional impediments and no explicit hierarchy between WHO and WTO agreements) were still too strong for some: the United States and Germany, although unable to block the global consensus, nevertheless signalled their continuing objection.9

It is unlikely that the few dissenting countries will succeed in blocking agreement at the World Health Assembly later this month, and the process of signing and ratifying the tobacco treaty will begin this summer. Already the treaty has had an impact, because it has prompted countries to reflect on and review their tobacco policies. Measurable improvements should soon be seen in global public health as governments implement treaty provisions.

However, this does not mean that we can breathe easy and go on to the next public health challenge. Continuing efforts are needed at national and regional levels to push governments to take the actions that the treaty, as a framework document, encourages rather than requires. For example, Canada's health minister seems to be stalling previous commitments to ban terms such as “light” and “mild” on cigarette packages,13 and provincial governments have not yet banned smoking in indoor public places and workplaces.

The treaty offers hope beyond tobacco control. It signals a new era of rules-based global governance. This month, we may be one step closer to a world where existing rules that favour economic and commercial interests are balanced and enriched by international rules that favour public health and well-being.

## Footnotes

*   *Competing interests:* None declared.

## References

1.  1. Fifty-sixth World Health Assembly provisional agenda item 13 [WHO Framework Convention on Tobacco Control]. Document A56/8. Geneva: World Health Organization; 2003 Apr 10. Available: [www.who.int/gb/EB\_WHA/PDF/WHA56/ea568.pdf](http://www.who.int/gb/EB_WHA/PDF/WHA56/ea568.pdf) (accessed 2003 Apr 22).
    
    

2.  2. World Health Organization. *The Framework Convention on Tobacco Control: a primer*. Geneva: The Organization; 2003. Available: www5.who.int /tobacco /page.cfm?sid=41 (accessed 2003 Apr 22).
    
    

3.  3. Slama K, editor. *Tobacco and health* [proceedings of the ninth World Conference on Tobacco or Health; 1994 Oct 10–14; Paris]. New York: Plenum Press; 1995.
    
    

4.  4. Intergovernmental Negotiating Body on the WHO Framework Convention on Tobacco Control, World Health Organization. *Draft WHO framework convention on tobacco control*. Geneva: The Organization; 2003. Publ no A/FCTC/INB6/5. Available: [www.who.int/gb/fctc/PDF/inb6/einb65.pdf](http://www.who.int/gb/fctc/PDF/inb6/einb65.pdf) (accessed 2003 Apr 11).
    
    

5.  5. Canadian Cancer Society, Heart and Stroke Foundation of Canada and Physicians for a Smoke-Free Canada. *New global tobacco treaty welcomed* [press release]. Ottawa: Physicians for a Smoke-Free Canada; 2003 Feb 28. Available: [www.smoke-free.ca/eng\_home/news\_press\_Feb28-2003.htm](http://www.smoke-free.ca/eng_home/news_press_Feb28-2003.htm) (accessed 2003 Apr 11).
    
    

6.  6. *The Canadian Tobacco Use Monitoring Survey (CTUMS): summary of results for wave 1 (February to June of 2002)*. Ottawa: Health Canada; 2003. Available: [www.hc-sc.gc.ca/hecs-sesc/tobacco/research/ctums/2002/summary.html](http://www.hc-sc.gc.ca/hecs-sesc/tobacco/research/ctums/2002/summary.html) (modified 2003 Jan 21; accessed 2003 Apr 11).
    
    

7.  7. Murray CJL, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0140-6736(96)07495-8&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9164317&link_type=MED&atom=%2Fcmaj%2F168%2F10%2F1263.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1997WZ76500011&link_type=ISI) 

8.  8. Steering Committee of the National Strategy to Reduce Tobacco Use in Canada, with Advisory Committee on Population Health. *New directions for tobacco control in Canada: a national strategy*. Ottawa: Health Canada; 1999. Cat no H39-505/1999. Available: [www.hc-sc.gc.ca/hecs-sesc/tobacco/pdf/new\_directions\_en.pdf](http://www.hc-sc.gc.ca/hecs-sesc/tobacco/pdf/new_directions_en.pdf) (accessed 2003 Apr 11).
    
    

9.  9. Framework Convention Alliance. *Statement of the Framework Convention Alliance. Tobacco treaty advances strong measures: full implementation key*. Geneva: The Alliance; 2003. Available: [www.fctc.org/press33.shtml](http://www.fctc.org/press33.shtml) (accessed 2003 Apr 11).
    
    

10. 10. Brown P. African states call for ban on tobacco advertising. BMJ 2001;322:1139.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE1OiIzMjIvNzI5NS8xMTM5L2EiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY4LzEwLzEyNjMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

11. 11. Bush's stealth tactics threaten anti-smoking gains. USA Today 2001 Jun 1; Sect A:15.
    
    

12. 12. Callard C, Collishaw N, Swenarchuk M. *An introduction to international trade agreements and their impact on public measures to reduce tobacco use*. Physicians for a Smoke-Free Canada and Commonwealth Medical Association; 2001. Available: [www.smoke-free.ca/pdf\_1/Trade](http://www.smoke-free.ca/pdf_1/Trade)&Tobacco-April 2000.pdf (accessed 2003 Apr 11).
    
    

13. 13. Tobacco industry. Canada: House of Commons debates (Hansard). 37th Parliament, 2nd sess, 2003 Mar 25, no 077.