Laurent Huber, Director, Framework Convention Alliance, Geneva, Switzerland
The World Health Organization Framework Convention on Tobacco Control is the governments’ response to the global tobacco epidemic and a blueprint for preventing one billion deaths this century. However, implementation in the ten years since its adoption has been sporadic, in part due to lack of whole-of-government engagement and inadequate resources. Ending this epidemic will require a harmonized approach that incorporates local, national, regional and global law as well as international trade, finance, health and development processes.Download here
Tobacco is unique. It is the only consumer product that, when used exactly as intended, kills its consumers. The World Health Organization (WHO) estimates that 1 billion people will die this century if action is not taken. Currently, about 6 million people per year are killed by tobacco, and most of these deaths occur in low-income countries, where many people are already at risk from other diseases.1,8 A 2013 United Nations Development Programme (UNDP) report states that by 2030, 70% of tobacco-related deaths will be in low- and middle-income countries and that in every region of the world, lower-income groups are more likely to use tobacco.2
Not only is tobacco the second leading health risk factor globally behind high blood pressure3, but it also robs families of financial resources that would otherwise go toward shelter, food, education and health care.2 Tobacco use heightens poverty within households and reduces productivity at the national level. Having a tobacco-related disease will hinder the main wage earner’s ability to work, which in turn reduces household wages and drives the family further into poverty.2 Additionally, tobacco farming undermines food security and environmental sustainability as about 90% of tobacco is grown in tropical dry forest and woodland areas in low-income countries that have high population densities and that are experiencing high biodiversity loss. Tobacco as a mono-crop depletes soil nutrients at a much faster rate than other crops.4 It can also impoverish some tobacco farmers who find themselves in bonded labour contractual arrangements that leave them trapped in a vicious circle of debt, resulting in poverty or situations where children as young as five years of age are used in tobacco farming, contravening basic human rights and labour conventions.5
Tobacco is the single greatest preventable cause of death in the world today.1 This has been recognized at the highest levels. The global community responded vigorously to the tobacco epidemic, by adopting the world’s first modern-day public health treaty, the WHO Framework Convention on Tobacco Control (FCTC) in 2003. The FCTC now has 177 Parties representing 88% of global population. A decade later, we are starting to see the fruits of the FCTC in a number of countries. In 2011, the second-ever United Nations health summit adopted a political declaration on non-communicable diseases (NCDs*), for which tobacco is a leading risk factor, which calls for an accelerated implementation of the FCTC. As a consequence, the World Health Assembly has adopted a Global Action Plan for the prevention and control of NCDs which also calls for an accelerated implementation of the FCTC along with the target of a 30% reduction in tobacco use by 2025. A number of countries including Finland and New Zealand have articulated some form of tobacco-free goal for their countries. This global recognition of the tobacco epidemic paired with targets and a global consensus around what measures are effective to reduce smoking prevalence are very positive advances in favour of public health, but there are also a number of challenges ahead.
The FCTC is a blueprint for preventing the one billion tobacco-related deaths that are predicted this century* but its implementation in the ten years since its adoption has been sporadic. From a governance standpoint – both at the national and global levels – we have been driving with one foot on the accelerator and one foot on the brake. This is in part because of a lack of whole-of-government engagement in its implementation, which has produced uncoordinated responses to addressing tobacco control measures at both national and international levels. This is both the cause and the result of limited political will and inadequate resources at the national level for the implementation of the FCTC.
In addition, a number of evidence-based national health policies consistent with the FCTC are under attack by the tobacco industry, which uses any available avenue to undermine governments’ efforts to protect the health of their citizens. Our only hope for ending this epidemic is to adopt a harmonized approach, vertically and horizontally, that incorporates local, national, regional and global law as well as trade, finance, health, and development processes. Unfortunately, there are those in and out of government who still see the tobacco industry as a legitimate stakeholder in this realm, and argue that somehow a compromise can be reached between the tobacco industry and public health, and that there is an acceptable level of preventable death.
British American Tobacco (BAT) and the China National Tobacco Corporation (CNTC) recently agreed to a joint venture to market Chinese and British cigarettes around the globe. CNTC is the world’s largest tobacco company, but its products – often much cheaper than brands from Japan and the West – have been sold almost exclusively in the Chinese market until now. BAT has decades of experience marketing cigarettes to the global South. The combination of marketing heft and cheap package price adds up to an imminent public health catastrophe for the world’s poorest populations, living in countries that often lack the most basic tobacco control measures.
At the same time, two trade agreements currently being negotiated threaten to exacerbate the problem. The Trans-Pacific Partnership (TPP) Agreement includes Australia, Brunei, Chile, Canada, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the United States and Vietnam. China and other countries have indicated their interest in joining. The TPP has been lauded as the model trade agreement for the twenty-first century, but it goes far beyond traditional trade issues such as tariffs and subsidies. Some analysts have even called it a “deregulation treaty”. The current draft includes powerful new rights for corporations, including the right to directly sue governments over regulations that they claim harm their profits; this includes tobacco control measures. The TPP is in its final negotiating phase and, once completed, will be the world’s biggest trading block.
Meanwhile, negotiations began in July on the Trans-Atlantic Trade and Investment Partnership (TTIP) between the United States and the European Union, with the United States pushing the TPP as the starting point for talks. Once completed, the TTIP would be even bigger than the TPP, encompassing the world’s two largest economies. If tobacco companies are able to use loopholes in these trade agreements to undermine public health polices then the repercussions on smoking prevalence could be noticeable. To put this into perspective, after the United States used trade rules to force open Asian markets to western tobacco multinationals in the 1980s, smoking prevalence jumped by more than 10% within a year6 and those cigarettes were more expensive than the domestic brands. These are just a few examples of tobacco industry partnerships and trade liberalization processes that benefit the tobacco industry that could have devastating impacts on global health and development: by drowning markets in high-income countries and in developing countries in Africa, Latin America and Asia with cheap cigarettes. With the global NCDs epidemic on the rise – and predicted to cost US$ 47 trillion by 20307 – this is not what the world needs. Governments must be empowered to attain their public health objectives. However, the tobacco industry has already taken advantage of existing trade and investment agreements to oppose governments’ efforts to protect the health of their citizens. For example, Philip Morris International has challenged Uruguay’s graphic health warnings and restrictions on cigarette packages under the bilateral investment treaty (BIT) between Switzerland and Uruguay. Given such actions, negotiators of the TPP and TTIP must seriously consider the advice of civil society advocates to exempt tobacco from the final agreements. Governments must ensure that trade and investment agreements are not used to undermine their public health policies, including measures to combat the tobacco epidemic. Carving tobacco out of trade rules can be an essential tactic to save millions of lives, especially in developing countries vulnerable to the tobacco industry’s political pressure and marketing tactics.
If the global community is serious about implementing strategies to tackle the tobacco epidemic, there is another timely opportunity for reversing current trends.
With less than two years until the current UN Millennium Development Goals (MDGs) expire, governments have begun discussing what development goals they should be trying to achieve after 2015. The post-2015 development agenda, which will determine a new set of sustainable development goals (SDGs), provides a unique opportunity to remind world leaders about their health commitments and the need to focus on reducing the global toll caused by tobacco. Tobacco was left out of the MDGs. This was a missed opportunity to raise awareness amongst policy-makers about the tobacco epidemic and it limited the development resources that were devoted to implementing the tobacco control measures in the FCTC. However, the SDGs will focus on sustainable development, and given that tobacco use impacts nearly all areas of sustainable development – including health, economic development, environmental sustainability and social inclusion – supporting public health measures to reduce tobacco prevalence should be a key strategy to accelerating sustainable development. The groundwork has been laid. United Nations Member States could make tobacco control a global development priority by including in the SDGs, under an overarching health goal, the World Health Assembly target of a 30% relative reduction in tobacco prevalence by the year 2025.
Implementing the FCTC’s measures would be the next step. These include increasing the price of tobacco products, comprehensively banning tobacco advertising, promotion and sponsorship, providing access to tobacco dependence treatment, requiring smoke-free public spaces, and mandating large, effective pictorial health warnings on cigarette packages.
In 2003, the world’s governments were unanimous in their decision to confront the tobacco epidemic by adopting the WHO FCTC. Unfortunately, that decision has not been universally implemented by governments and via intergovernmental processes. It is well past time that it was, and that stakeholders stopped recognizing “Big Tobacco” as just another industry and started seeing it for what it truly is: the vector for the world’s Number One cause of preventable death. Left unchecked, the tobacco epidemic risks undermining the progress made in global development over the past 50 years.
If governments are willing to exempt tobacco out of trade agreements, address the tobacco epidemic as a key development priority in the post-2015 development agenda, and accelerate the implementation of the FCTC, it is very likely that we can move the tipping point in favour of health and save hundreds of millions of lives.
2. United Nations Development Program. Discussion Paper. Addressing the Social Determinants of Noncommunicable Diseases; October 2013.
3. The World Health Organization. Global Health Risks. WHO Mortality and burden of disease attributable to selected major risks http://www.who.int/healthinfo/ global_burden_disease/GlobalHealthRisks_report_part2.pdf
4. Goodland JA, Watson C, Ledec G. Environmental management in tropical agriculture. Boulder, CO, Westview Press, 1984.
5. The International Labour Organization conventions on child labour are available from: http://www.ilo.org/ipec/facts/ILOconventionsonchildlabour/lang–en/index.htm; information on international conventions on child labour is available from: http://www.un.org/en/globalissues/briefingpapers/childlabour/intlconvs.shtml.
6. Wen, CP et al, The impact of the cigarette market opening in Taiwan, Tob Control 2005.
7. The Global Economic Burden of Non-communicable Diseases. Harvard School of Public Health. The World Economic Forum. 2011. http://www.weforum.org/reports/global-economic-burden-non-communicable-diseases
8. Marquez PV, Farrington, J. L. . The Challenge of Non-Communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa. An Overview. Washington, DC: The World Bank; 2013.