The fourth round of negotiations for the first-ever proposed international health treaty bogged down last month in Geneva, when delegates from more than 150 nations began haggling in earnest over the details. The impasse is not surprising, observers say, given the enormity of what this treaty, sponsored by the World Health Organization, is attempting to docontrol the tobacco industry globally to reduce use of cigarettes and lessen the resulting burden of illness and death.
Use of tobacco is the single largest preventable cause of death in the world today, and the only one that has corporate sponsorship, WHO officials noted. Tobacco-related diseases, such as lung cancer, kill more than 4.2 million people annuallymore than the recognized public health scourges of AIDS and malaria combined. (One tenth of those deaths, or 400,000, are in the United States.) By 2020, an estimated 8.4 million people will die each year from tobacco-related diseases, and more than two-thirds of those deaths will occur in developing countries.
"Women and the young are taking up smoking in higher numbers, and almost half of the worlds children are exposed to second-hand smoke," Ambassador Luiz Felipe de Seixas Correa, chairman of WHOs Intergovernmental Negotiation Body of the Framework Convention on Tobacco Control, told delegates to the tobacco treaty negotiations at the opening ceremony on March 18. "One out of two children who start smoking today will die before middle age.
"Despite all this evidence, marketing and advertising strategies, in developing as well as developed countries, promote the view that smoking is normal behavior," he told world delegates. But WHOs observation is that use of tobacco is a worldwide "epidemic" and that the only way to control it is to manage the power of the tobacco industry. Said de Seixas Correa, the treaty represents "a political process brought in to serve a public cause."
By all accounts, the effort to design a global tobacco treaty has become divisive, although many hope WHOs proposed May 2003 deadline for passage can still be met. But the reach and scope of the treaty is under fierce debate. An international treaty could spell out exactly what tobacco companies can and cannot do, providing a tool that each nation can ratify with the force of law. At its most extreme, the treaty could give nations the right to ban all tobacco marketing, and impose prohibitive import tariffs on cigarettes.
The process began in 1995, after the WHOs governing body, the World Health Assembly, looked into the possibility that a mechanism to help control tobacco could be written into a legally binding international treaty. Over the past 25 years, the assembly has adopted 16 different resolutions covering different aspects of tobacco control, but it was a piecemeal effort with varying degrees of success. In 1999, negotiations began on the treaty, formally called the Framework Convention on Tobacco Control.
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Nations pushing for comprehensive tobacco control are those in the global south, including 46 African nations, said Lynn, who attended the Geneva meeting. "Africa is already dealing with a lot of health issues and sees the tobacco epidemic as one that is manmade. The treaty presents an opportunity to stop it before it takes hold." Also supporting a strong treaty are such Middle Eastern countries as Iran and Iraq, who fear the health impact tobacco represents, she said.
Infact is one of many nongovernmental organizations working as treaty advocates. Other U.S. groups include the Campaign for Tobacco-Free Kids, the American Lung Association, the American Cancer Society, the American Heart Association, and the American Thoracic Society. An umbrella organization, the Framework Convention Alliance, representing more than 160 nongovernmental organizations from around the world, has taken the position that the treaty must be both tough and enforceable.
The top issues the Framework Convention Alliance identified as key to global tobacco control are the ones that are already on the table for treaty discussion. They include: a ban on all forms of direct and indirect tobacco advertising, promotion and sponsorship, except where constitutionally protecteda position many countries endorse; control on "tariff-free" smuggling, which now accounts for one-third of all internationally traded cigarettes; clear warning labels and other markings on cigarettes; a ban on misleading brand names such as "light," "mild," and "ultra low," which imply health claims not backed by science; increasing cigarette taxes to reduce demand, especially among the young; and efforts to eliminate second-hand smoke by establishing smoke-free areas.
But perhaps the issue of most contention is the provision controlling free trade, said Judith Wilkenfeld, director for international programs at the Campaign for Tobacco-Free Kids. The Framework Convention Alliance maintains that matters of health must supercede free trade commercial interests. That is, if a country believes it is in the interest of the health of its citizens to impose high tariffs on imported tobacco or impose severe restrictions on the sale of foreign cigarettes, that concern outweighs other international treaties that support free trade between countries. It is a position similar to one recently adopted in which countries have agreed to a health exception to international patent rules so that developing nations could have access to affordable AIDS drugs.
"If the Framework Convention does not explicitly state that its public health provisions are to take priority when they conflict with trade rules, it will allow the tobacco industry to seek to overturn other provisions of the convention, as well as tobacco control measures enacted by nations, as trade violations," said Wilkenfeld. "The issue that health is more important than trade is the top provision, from which everything else will follow."
New to the discussion this year is the possibility of using American-style litigation to fight big tobacco in other countries. D. Douglas Blanke, a former assistant Minnesota attorney general involved in that states successful tobacco lawsuit, authored a lengthy primer on litigation as a tool for tobacco control that was released last month, just as negotiations got under way.
While using the justice system to fight transnational tobacco corporations may be a difficult proposition in many countries, it can result in at least two very effective tobacco control measures, Blanke saidforcing tobacco companies to raise the price of its product to pay for litigation and inducing the media to spread damaging information from lawsuit testimony. Just the process of negotiating the tobacco treaty is already educating the worlds countries about the power and tactics of tobacco companies, said Blanke, who also attended the Geneva meeting. "I can clearly see that education, as a goal in and of itself, is already being achieved," he said.
The fractious stance taken by the American delegation in the last several negotiating sessions is explained by the fact that the United States exports more cigarettes than any other nation in the world, say activists. "The United States and Japan, home to two of the three biggest tobacco companies in the world, most clearly play an obstructive role," said Infacts Lynn.
Jeffrey Glassroth, M.D., past president of the American Thoracic Society, agreed. "The current U.S. delegation has consistently opposed basic public health measures that we know would be effective in reducing tobacco use, including a ban on tobacco advertising, a ban on promotion and sponsorship, a ban on duty-free sales, a ban on smoking in workplaces, strong warning label provisions, and increased tobacco taxes."
U.S. Rep. Henry Waxman (D-Calif.) also complained that the American delegation is guided by political influence. At the second session of treaty negotiations last May, the U.S. delegation appointed by the new administration reversed previous positions and deleted 10 of the 11 positions tobacco giant Philip Morris had urged be struck, Waxman said. Writing in the March 21 "Sounding Board" column of the New England Journal of Medicine, Waxman said, "From my vantage point as a legislator who has long battled the tobacco industry, I see a connection between the industrys pervasive political influence and the weaknesses in the current administrations negotiating positions."
Mark Berlind, a spokesman for Philip Morris Management Corp., said that the tobacco industry has a "constructive role" to play in treaty negotiations, yet has not been given a formal voice. "We asked WHO to give us a seat at the table like it has the nongovernmental organizations and the activists. WHO has permitted one point of view to be expressed, but not ours," he said. Unlike some other tobacco companies, Philip Morris supports a "sensible" treaty that can advance tobacco regulation that will, among other things, reduce youth smoking, disclose tobacco product ingredients, and reduce smuggling, Berlind said. What the company does not support, however, are measures calling for an increase in cigarette taxes, the idea that litigation should be part of a treaty, and, of major concern, "any notion that general trading principles of the World Trade Organization should not apply," he said.
Blanke said the American delegation does not want to take any position in the treaty that goes beyond what the United States already does to control tobacco. But he said the big surprise of treaty negotiations is the innovative approaches that countries "from Scandinavia to Thailand" are taking to counteract the tobacco epidemic. "We have as much to learn from other countries as they have to learn from us," he said. "The treaty has the potential to set a global benchmark for best practices that can reframe the debate in our own country. This is eye-opening to most of us."
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