Tobacco control, global health policy and development: towards policy coherence in global governance

The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.     

The precautionary principle and other non-tariff barriers to free and fair international food trade

International food trade and world population are growing rapidly. National legislation has been enacted and implemented in many countries to assure good quality and safe foods to meet increased demand. No country is fully self-sufficient in domestic food production to meet population demands, and all require some food imports. Current international food trade agreements call for free and fair food trade between all countries, developed and developing. National food legislation and food production, processing and marketing systems have evolved in most countries to ensure better quality and safer foods. At the international level the work of the FAO/ WHO Codex Alimentarius Commission (Codex) and the World Trade Organization Agreements on Sanitary and Phytosanitary Measures (SPS) and on Technical Barriers to Trade (TBT) and related Uruguay Round agreements have been agreed to by over 140 countries with the aim to promoting the free and fair trade of good quality and safe foods between all countries. The SPS and TBT agreements rely on science-based Codex standards, guidelines, and recommendations as benchmarks for judging international food trade disputes. A number of non-tariff barriers to trade, often related to agricultural subsidies and other food trade payments in developed countries, continue to give rise to complaints to WTO. They also continue to prevent free and fair trade, particularly for developing countries in international food trade. A number of these non-tariff barriers to trade are briefly examined, along with other domestic and international food trade problems, and recommendations for improvements are made.     

The Textile and Apparel Industry in Developing Countries

The textile and apparel industry is the gate of choice for most developing countries in their quest to step into industrialization. The ease of entry into this field and the abnormally high wages in developed countries have created favorable conditions for the manufacturing and the exportation of textile and apparel derived products. At the same time, this unique situation has effected a cutthroat competition among the many actors while fueling an intense protectionism in many developed countries where the export markets are found. However, paradoxically, it is the U.S. trade policies that have been the common factor in the flourishing of the textile and apparel industry in many countries and regions around the world. From Asia, this generous openness has in time reached the Caribbean region and finally Sub-Saharan Africa. The evolution of this fluid industry in developing countries is examined within the boundaries of the textile and apparel managed trade agreements. It is argued that successes in this field must come from the combined efforts of the local government's industrial and trade policies, the entrepreneurial prowess of the private sector and the flexibility and the work ethic of the labor force. From the SE Asia NICs, to the Caribbean states and the Sub-Saharan African region, the synergy created by the U.S. trade policies and the local capabilities is shown to be the major ingredient for the development of the textile and apparel sector in scores of developing countries.     

Tobacco industry successfully prevented tobacco control legislation in Argentina

Objective: To evaluate how transnational tobacco companies, working through their local affiliates, influenced tobacco control policymaking in Argentina between 1966 and 2005. Methods: Analysis of internal tobacco industry documents, local newspapers and magazines, internet resources, bills from the Argentinean National Congress Library, and interviews with key individuals in Argentina. Results: Transnational tobacco companies (Philip Morris International, British American Tobacco, Lorillard, and RJ Reynolds International) have been actively influencing public health policymaking in Argentina since the early 1970s. As in other countries, in 1977 the tobacco industry created a weak voluntary self regulating code to avoid strong legislated restrictions on advertising. In addition to direct lobbying by the tobacco companies, these efforts involved use of third party allies, public relations campaigns, and scientific and medical consultants. During the 1980s and 1990s efforts to pass comprehensive tobacco control legislation intensified, but the organised tobacco industry prevented its enactment. There has been no national activity to decrease exposure to secondhand smoke. Conclusions: The tobacco industry, working through its local subsidiaries, has subverted meaningful tobacco control legislation in Argentina using the same strategies as in the USA and other countries. As a result, tobacco control in Argentina remains governed by a national law that is weak and restricted in its scope.     

Opportunities and risks of the proposed FCTC protocol on illicit trade

Illicit trade in tobacco products presents a threat to public health because it undermines the use of tax and price policies, which are among the most effective mechanisms for reducing tobacco consumption. Parties to the WHO Framework Convention on Tobacco Control (FCTC) are in the final stages of negotiating a protocol aimed at strengthening international cooperation in the fight against illicit tobacco trade. While an effective multilateral response to illicit tobacco trade would make a significant contribution to global tobacco control, achieving this through the FCTC forum is challenging. First, while illicit tobacco trade is a health problem, the expertise, experience and capacity needed to combat illicit trade are not traditionally found in health agencies. The development of links with other agencies, both domestic and international, is critical to ensure both an effective response and an efficient use of limited governmental and non-governmental resources. Second, in many parts of the world, the tobacco industry cooperates closely with governments in the combating of illicit trade. This cooperation poses risks for tobacco control, particularly if relationships and norms of cooperation spill over into other areas of FCTC implementation. An examination of the industry's positioning suggests that it sees an opportunity to portray itself as 'legitimate' and 'responsible', a friend of governments, and a way to integrate itself into FCTC processes. This paper makes suggestions for moving forward in this challenging area towards ensuring that the approach taken actually reduces illicit tobacco trade, strengthens tobacco tax policies and does not operate to undermine the FCTC.     

Framing tobacco control efforts within an ethical context

Public health efforts to promote tobacco control are not performed within a vacuum. They are subject to interpretation and misinterpretation by consumers and policymakers based largely upon the initial framing of the issues. This paper notes how the tobacco industry has established a particular frame that it is the protector of individual rights and that the public health community is trying to eliminate those rights. This paper then shows how the public health community uses metaphors that may unintentionally support this framing and suggests that by reframing public health efforts in accordance with core ethical principles, the public health community can create more positive messages. A public health ethical framework is proposed to examine how the application of the principles can influence the tobacco control movement. Through the increased use of ethics in tobacco control, the public health community may be better positioned to claim the high road as the protector of the public's interests.     

Social movements and human rights rhetoric in tobacco control

After achieving breathtaking successes in securing state and local restrictions on smoking in public places and restricting youth access to tobacco products, the tobacco movement faces difficult decisions on its future strategic directions. The thesis of this article is that the tobacco control movement is at a point of needing to secure its recent successes and avoiding any public retrenchment. To do so requires rethinking the movement's strategic direction. We use the familiar trans-theoretical model of change to describe where the movement is currently and the threats it faces. The new tobacco control strategy should encompass a focus on voluntary non-smoking strategies, use human rights rhetoric to its advantage, and strengthen the public health voice to be more effective in political battles. In developing a new strategy, tobacco control advocates need to build a social movement based on a more forceful public health voice, along with the strategic use of human rights rhetoric, to focus on the power of voluntary non-smoking efforts. Using human rights rhetoric can help frame the movement in ways that have traditionally appealed to the American public. Perhaps more importantly, doing so can help infuse the tobacco control movement with a broader sense of purpose and mission.     

Globalisation of tobacco industry influence and new global responses

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.     

Whose standard is it,anyway? How the tobacco industry determines the International Organization for Standardization (ISO) standards for tobacco and tobacco products

OBJECTIVE: To describe the extent of the tobacco industry involvement in establishing international standards for tobacco and tobacco products and the industry influence on the International Organization for Standardization (ISO). METHODS: Analysis of tobacco industry documents made public as part of the settlement of the Minnesota Tobacco Trial and the Master Settlement Agreement. Search words included "ISO", "CORESTA", "Barclay", "compensation and machine smoking", "tar and nicotine deliveries", and the name of key players, in different combinations. RESULTS: It is clear that the tobacco industry, through the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA), play a major role in determining the scientific evidence and suggesting the standards that are eventually adopted as international standards for tobacco and tobacco products in several areas, including the measurement of cigarette tar and nicotine yield. CONCLUSIONS: ISO's tobacco and tobacco products standards are not adequate to guide tobacco products regulatory policies, and no health claims can be made based on ISO's tobacco products standards. There is an urgent need for tobacco control advocates and groups worldwide to be more involved with the work of the ISO, both directly and through their national standardisation organisations.     

Building capacity for tobacco control research and policy

The Fogarty International Center (FIC) initiative, "International Tobacco and Health Research Capacity Building Program" represents an important step in US government funding for global tobacco control. Low- and middle-income countries of the world face a rising threat to public health from the rapidly escalating epidemic of tobacco use. Many are now parties to the Framework Convention on Tobacco Control (FCTC) and capacity development to meet FCTC provisions. One initial grant provided through the FIC was to the Institute for Global Tobacco Control (IGTC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to support capacity building and research programmes in China, Brazil, and Mexico. The initiative's capacity building effort focused on: (1) building the evidence base for tobacco control, (2) expanding the infrastructure of each country to deliver tobacco control, and (3) developing the next generation of leaders as well as encouraging networking throughout the country and with neighbouring countries. This paper describes the approach taken and the research foci, as well some of the main outcomes and some identified challenges posed by the effort. Individual research papers are in progress to provide more in-depth reporting of study results.     

Evolution of the international regulation of plant pests and challenges for future plant health

Plant pathogens and invertebrates harmful to plants, collectively referred to as plant pests, continue to threaten food security. International cooperation and regulatory systems to inhibit the spread of plant pests began formally in 1878. Initially seven countries worked together and agreed phytosanitary measures against grape phylloxera, Phylloxera vastatrix (=Daktulosphaira vitifoliae). There are now 172 countries that are contracting parties to the International Plant Protection Convention, a treaty that aims to prevent the introduction and spread of pests of plants and plant products, and to promote appropriate measures for their control. Apparently contradictory interests between international trade, which has facilitated the spread of plant pests, and the protection of plants are mutually recognised in global trade and phytosanitary agreements. The principle that risk management measures should provide an appropriate level of protection without undue interference in trade was established within the plant protection agreements at the beginning of the 20th Century and is still fundamental to risk management policy today. Globally ten Regional Plant Protection Organizations facilitate more local cooperation and recommend the regulation of over 1,000 named quarantine plant pests. Member States of the European Union work together and regulate imported plant material on the grounds of plant health with each Member State taking into account the plant health concerns of every other Member State. However, decision making can be slow and border inspections poorly targeted. Close relationships between regulatory scientists and policy makers, focussed on agricultural and horticultural production, are changing to take a broader stakeholder community into consideration as decisions regarding the environment seek to draw upon a wider knowledge base. Challenges that impede the success of limiting international pest movement include increased international trade and climate change. International guidelines designed to prevent pest spread present challenges of their own if they remain difficult to implement.     

British Columbia capital regional district 100% smokefree bylaw: a successful public health campaign despite industry opposition

Objective: To describe how the British Columbia Capital Regional District successfully passed, implemented, and enforced a 100% smokefree bylaw in all public places, including restaurants and bars, despite an aggressive campaign by the tobacco industry (acting through the hospitality industry) to stop it. Methods: Information was obtained from news reports, internal tobacco industry documents, reports, public documents, and interviews with key players. Tobacco industry documents were accessed between February and April 2002. This project was approved by the University of California San Francisco committee on human research. Results: As in the USA and elsewhere in the world, the tobacco industry in British Columbia, Canada, recruited and created hospitality associations to fight against the district smokefree bylaw. They used the classic industry rhetoric of individual rights and freedoms, economic devastation, and ventilation as a solution. Public health authorities were able to counter industry strategies with a strong education campaign, well written bylaws, and persistent enforcement. Conclusion: It is possible to overcome serious opposition orchestrated by the tobacco industry and develop and implement a 100% smokefree bylaw in Canada. Doing so requires attention to detail in drafting the bylaw, as well as a public education campaign on the health dangers of secondhand smoke and active enforcement to overcome organised resistance to the bylaw. Jurisdictions considering smokefree bylaws should anticipate this opposition when developing and implementing their bylaws.     

British American Tobacco's tactics during China's accession to the World Trade Organization

Background

China entered the World Trade Organization (WTO) in 2001 after years of negotiations. As a WTO member, China had to reduce tariffs on imported cigarettes and remove non‐tariff barriers to allow foreign cigarettes to be more competitive in the Chinese market. Among foreign tobacco companies, British American Tobacco (BAT) was the most active lobbyist during China''s WTO negotiations.

Objective

To review and analyse BAT''s tactics and activities relating to China''s entry into the WTO.

Methods

Internal tobacco industry documents were reviewed and are featured here. Industry documents were searched mainly on the website of BAT''s Guildford Depository and other documents'' websites. 528 documents were evaluated and 142 were determined to be relevant to China''s entry into the WTO.

Results

BAT was extremely active during the progress of China''s entry into the WTO. The company focused its lobbying efforts on two main players in the negotiations: the European Union (EU) and the US. Because of the negative moral and health issues related to tobacco, BAT did not seek public support from officials associated with the WTO negotiations. Instead, BAT lobbyists suggested that officials protect the interests of BAT by presenting the company''s needs as similar to those of all European companies. During the negotiation process, BAT officials repeatedly spoke favourably of China''s accession into the WTO, with the aim of presenting BAT as a facilitator in this process and of gaining preferential treatment from their Chinese competitor.

Conclusions

BAT''s activities clearly suggest that tobacco companies place their own interests above public health interests. Today, China struggles with issues of tobacco control that are aggravated by the aggressive practices of transnational tobacco companies, tobacco‐tariff reductions and the huge number of smokers. For the tobacco‐control movement to progress in China, health advocates must understand how foreign tobacco companies have undermined anti‐tobacco activities by taking advantage of trade liberalisation policies. China should attach importance to public health and comprehensive tobacco‐control policies and guarantee strong protection measures from national and international tobacco interests supported by international trade agreements.China is the largest tobacco producing and consuming country in the world, with over 350 million smokers in a population of 1.2 billion.^1,2 China''s cigarette market is dominated by a state‐owned monopoly, the State Tobacco Monopoly Administration, which strongly protects the domestic tobacco industry.³ This largest cigarette market in the world is nearly 3½ times the size of the US cigarette market and over 12 times the size of the German cigarette market, which is the largest in Western Europe.⁴ However, as smoking rates have fallen in North America and Western Europe,⁵ transnational tobacco companies (TTCs) from the US and Great Britain have turned to international cigarette markets to seek greater profits.China entered the World Trade Organization (WTO) in 2001 after years of negotiations.⁶ As a condition of WTO membership, China had to reduce tariffs on imported cigarettes and remove non‐tariff barriers to allow greater competitiveness for foreign cigarettes in the Chinese market.⁷ O''Sullivan and Chapman⁸ and Lee et al⁹ studied TTC industry documents and described TTC aims and conduct in China. Those studies mainly focused on the heavy reliance on contraband and the undermining of national advertising bans. However, no previous papers have examined China''s entry into the WTO on the basis of tobacco‐industry documents. British American Tobacco (BAT) was engaged in the most active lobbying during China''s accession to the WTO. This paper reviews and analyses BAT documents related to China''s WTO negotiations to clarify BAT''s tactics and use of international trade policies to support their corporate interests.     

African American leadership groups: smoking with the enemy

BACKGROUND: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown. OBJECTIVE: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. METHODS: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. RESULTS: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. CONCLUSION: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.     

Plenary Lecture 7: One World For All: International Harmonization of Food Regulations

ABSTRACT: Although the Codex Alimentarius Commission has functioned as part of the United Nations' Food and Agriculture Organization since 1962, its activities have been of little more than occasional interest until recent years. However, with the advent of the World Trade Organization (WTO) and the establishment of the North American Free Trade Agreement (NAFTA) and other trading blocs, the deliberations of Codex have become significantly more important to the international trade interests of government and industry groups alike. Increased interest in the elaboration of Codex standards, guidelines, and recommendations may be attributed to increased international awareness of 2 very practical functions of the Commission and its numerous committees. First, some countries have become aware that the guidance and information needed to fill in their own regulatory gaps are often made available in the Codex. Second, multinational corporations and trade associations have become aware of the role that Codex has been given in the WTO agreements as the means by which disputes over trade in food products may be resolved. Increased awareness of the practical functions of Codex activities in shaping national legislation and establishing international trade standards appears to have strengthened Codex's role as the focal point of efforts to achieve internationally harmonized food standards. However, many international regulatory gaps show signs of being filled by legislation that imposes burdens on industry without demonstrable benefits to public welfare. In their most troublesome manifestations, some of these measures, especially recent regulations concerning biotech food labeling, could be viewed as technical barriers to trade.     

What public health strategies are needed to reduce smoking initiation?

Smoking initiation is a key behaviour that determines the future health consequences of smoking in a society. There is a marked difference in smoking patterns around the world, driven by initiation rates. While a number of high-income countries have seen smoking prevalence decline markedly from peak, many low-income and middle-income countries appear to still be on an upward trend. Unlike cessation where changes are limited by nicotine dependence, rates of smoking initiation can change rapidly over a short time span. Interventions that can be effective in achieving this include increases in the price of tobacco products, mass media anti-smoking advertising, smoke-free policies, smoking curricula in schools, restrictions on marketing opportunities for the tobacco industry as well as social norms that lead to restrictions on adolescents' ability to purchase cigarettes. Comprehensive tobacco control programmes that aim to denormalise smoking behaviour in the community contain all of these interventions. Rapid reductions in smoking initiation in adolescents have been documented in two case studies of comprehensive tobacco control programmes in California and Australia. Consistent and inescapable messages from multiple sources appear to be key to success. However, the California experience indicates that the rapid decline in adolescent smoking will not continue if tobacco control expenditures and the relative price of cigarettes are reduced. These case studies provide strong additional evidence of the importance of countries implementing the provisions of the Framework Treaty on Tobacco Control.     

International cigarette labelling practices

DESIGN: Cross-sectional study. PARTICIPANTS: Members of GLOBALink (), an Internet listserve for tobacco activists with members in 56 countries, who were asked to provide specific information on cigarette warning requirements in their countries. MAIN OUTCOME MEASURES: Presence of specific warning labels, overall content score (based on a 0-10 scale with a point for each specific warning mentioned), size of warning label, location of warning label. RESULTS: Forty-five countries (80%) responded; 40 had mandatory labelling requirements, three had voluntary agreements with the industry and two had no requirements. In general, American companies did no more in foreign countries than required by local law. The average developing country content score was 1.6, compared with 5.0 in developed countries (p = 0.0003). Forty-two per cent of countries either had no warning requirement or had only a very general health warning. The most common warning was for heart disease (49% of countries) and the least common was for addiction (14%). All warnings were more common in developed than developing countries. Warnings in developed country were on average 27% larger than those in developing countries (p = 0.325). Seventy-three per cent of labels in developing countries appeared only on the side of the pack, whereas 78% of labels in developed countries appeared on the front and back (p = 0.003). CONCLUSIONS: In almost every respect measured, residents in developing countries are receiving inferior information about the hazards of smoking than residents of developed countries. Laws should be promulgated in importing and exporting countries to ensure that, where their labelling laws differ, companies would be required to provide the more comprehensive labelling.     

Businesses' voluntary pro-health tobacco policies: a review and research agenda

Research on the role of businesses in tobacco control has focused primarily on retailers, advertising firms and the hospitality industry, all of which have tended to support tobacco industry interests and resist effective tobacco control policies. However, in several countries, businesses have a history of voluntarily adopting tobacco-related policies that may advance tobacco control objectives. These phenomena have received little research attention. Existing literature on businesses ending tobacco sales, instituting voluntary workplace smoking restrictions and establishing non-smoker only hiring policies was reviewed. A research agenda on voluntary business initiatives would enhance and complement research on mandatory tobacco control policies by identifying new advocacy opportunities; suggesting avenues for strengthening or reinforcing existing policy initiatives; laying the groundwork for new mandatory policies; helping to inform ethical debates about contentious voluntary policies; and contributing to a better understanding of how alliances between the tobacco industry and other businesses might be weakened.     

Tobacco and poverty: evidence from Vietnam

This review examined existing evidence to investigate the link between tobacco and poverty in Vietnam, to assess the impact of tobacco control policies on employment related to tobacco consumption and to identify information gaps that require further research for the purposes of advocating stronger tobacco control policies. A Medline, PubMed and Google Scholar search identified studies addressing the tobacco and poverty association in Vietnam using extensive criteria. In all, 22 articles related either to tobacco and health or economics, or to the potential impact of tobacco control policies, were identified from titles, abstracts or the full text. 28 additional publications were identified by other means. PHA, LTT and LTTH reviewed the publications and prepared the initial literature review. There is extensive evidence that tobacco use contributes to poverty and inequality in Vietnam and that tobacco control policies would not have a negative impact on overall employment. Tobacco use wastes household and national financial resources and widens social inequality. The implementation and enforcement of a range of tobacco control measures could prove beneficial not only to improve public health but also to alleviate poverty.