Kai Pfaffenbach / Reuters Two cigarettes replacing the hands of a clock to remind customers of the upcoming smoking ban, are pictured in the Weisses Roessl restaurant in Hanau, 30km (19 miles) south of Frankfurt, March 22, 2007.

Thank You for Not Smoking

How the WHO Fought Tobacco Through Treaties

Our modern world is defined by connectivity. Today’s communication tools spread information from the depths of the Amazon to the farthest reaches of Central Asia to New York City within seconds. But such networks have not, on the whole, led to the standardization of international regulations and norms, which has given rise to ethical and practical dilemmas for multinational companies, governments, and international organizations. The international smoking epidemic provides one of the best illustrations of what that means in practice.

The transnational tobacco industry has used trade liberalization, foreign direct investment, and global communications to expand its markets to low- and middle-income countries where effective tobacco control programs are not in place.

The consequences are staggering. Tobacco-related deaths, a completely man-made epidemic, are the leading cause of preventable death in the world. In 2013 alone, tobacco killed nearly six million people. More than five million of those deaths resulted from direct tobacco use, whereas more than 600,000 were the result of nonsmokers being exposed to secondhand smoke.

As evidence of a growing pandemic first started to emerge in the late 1970s, a committed group of individuals and organizations sought to challenge the tobacco industry’s expansion and to control tobacco use. They used modern communication technologies and virtual networks to spread information, coordinate activities, and elicit responses from local, national, and international authorities. The global response included, in 2003, the first ever negotiation of a binding international law under the auspices of the World Health Organization—the WHO Framework Convention on Tobacco Control (FCTC).

HEALTH HAZARDS

Scientists in Germany first began making statistical correlations between cancer and smoking in the 1930s. In 1938, Raymond Pearl, a biologist at Johns Hopkins University, reported that smokers do not live as long as nonsmokers. In 1953, epidemiologist Ernst Wynder demonstrated that cigarette tar caused tumors on the backs of mice, and in the following year, physiologist Richard Doll and epidemiologist Bradford Hill published a study of British doctors that found that smokers had a greater risk of lung cancer than comparable nonsmokers.

These early scientific studies provoked the tobacco industry, which in 1954 created the Tobacco Industry Research Committee to conduct its own scientific studies. At the same time, the industry began to mass-market filtered cigarettes and, later, low-tar formulations that promised a “healthier” smoke. The number of cigarettes with filters increased from two percent in 1950 to more than 50 percent in 1960. The strategy was effective and cigarette sales boomed.

A workman puts finishing touches on a billboard featuring a cowboy smoking a limp cigarette to illustrate sexual impotence as one of the risks of smoking in Hollywood, Calif., April 23, 1999 in Hollywood.

A workman puts finishing touches on a billboard featuring a cowboy smoking a limp cigarette to illustrate sexual impotence as one of the risks of smoking in Hollywood, Calif., April 23, 1999 in Hollywood.

All the while, the tobacco industry continued to deny the relationship between cigarette smoking and disease and pointed to its own research as evidence that smoking was not harmful or addictive. As recently as 1994, the top seven tobacco industry executives swore under oath to the U.S. Congress that they did not believe smoking to be addictive. However, in 1998, as a condition of settling ongoing litigation with the attorney general of Minnesota, the tobacco industry was forced to make available confidential documents that proved that the companies had been aware of the harmful effects of smoking since the mid-1950s and had implemented a strategy to hide this information to undermine the growing evidence base.

In spite of the early scientific consensus around the link between smoking and cancer, passing regulation was difficult. In the United States, the long-standing relationship between the federal government and the tobacco industry got in the way. Antismoking advocates faced similar barriers around the world. And even when regulations were created, implementing them proved nearly impossible. Between 1970 and 1998, the World Health Assembly (WHA), the decision-making body of the WHA, adopted 17 resolutions on different aspects of tobacco control. Although nations occasionally referenced these resolutions when passing national tobacco control legislation, the lack of any legally binding authority made the resolutions inconsequential.

STATING THEIR CASE

The idea of using WHO’s constitutional authority to establish a stronger international legal regime for tobacco control arose in 1979, when the WHO Expert Committee on Smoking Control suggested using the organization’s treaty-making power to develop binding obligations. Thanks to the technical work and lobbying efforts of two women, Ruth Roemer and Allyn Taylor, the idea of an international treaty on tobacco control was crystalized in the early 1990s. At the Ninth World Conference on Tobacco and Health in 1994, a resolution was successfully passed calling on national governments, ministers of health, and WHO to “immediately initiate action to prepare and achieve an International Convention on Tobacco Control to be adopted by the United Nations.” The conference marked the first international forum in which the idea of an FCTC was formally endorsed.

Cigarette boxes with an affixed self-made cigarette label displaying graphic images are pictured in the shop of tobacconist and kiosk owner Janine Schulzki in Berlin February 9, 2013.

Cigarette boxes with an affixed self-made cigarette label displaying graphic images are pictured in the shop of tobacconist and kiosk owner Janine Schulzki in Berlin February 9, 2013.

Never in its first 50 years of existence did WHO use its treaty-making power, though, in part because the organization was mainly staffed by medical doctors and scientists who traditionally focused on technical, clinical approaches to disease prevention and control. This changed with the election of former Norwegian Prime Minister Dr. Gro Harlem Brundtland as WHO director general in 1998. Key global tobacco control leaders were members of Brundtland’s transition team, and they were able to take advantage of their position to convince Brundtland that it was the right time of push a framework convention on tobacco control forward. There were many reasons why a tobacco treaty was attractive to Brundtland. First, after years of dysfunction, WHO needed strong, clear, and innovative leadership. Second, momentum for tobacco control was strong on the heels of the release of millions of pages of previously confidential tobacco industry documents resulting from litigation in the United States. Third, data on the health consequences, burden of disease, and economic evidence supporting tobacco control was available to justify global attention to the issue.

Formal negotiations of the FCTC began in October 2000, and on May 21, 2003, the FCTC was unanimously adopted by the World Health Assembly. The treaty entered into force on February 27, 2005 after the first forty countries ratified it. Ten years after its adoption, 180 countries, representing nearly 90 percent of the world’s population, had ratified the treaty.

Pablo La Rosa / Reuters People walk past near an anti-tobacco installation in Montevideo November 16, 2010

THE GREATER GOOD

From the start of the FCTC process, WHO officials claimed that the power of the treaty rested within the process of its creation, not just in the document itself. The negotiating process, they argued, would intensify international communication about tobacco, and the information shared would accelerate the passage of tobacco control policies throughout the world. There is some truth to that: the negotiations surrounding the FCTC vaulted tobacco control up to the top of political agendas, led to intense information sharing among health experts and advocates and, eventually, created the simultaneous adoption of tobacco control policies in numerous, diverse countries. Legislative prominence prompted increased philanthropic investment in tobacco control policy—which led to international training, capacity building, and collaboration.

But the merits of actual agreement stand on their own as well. FCTC-relevant policies have been adopted worldwide. These polices are expected to save 7.5 million lives by 2050.

The global war on tobacco, and the FCTC process in particular, has broad implications for other areas of global health governance—especially those attempting to address public health problems defined by modern lifestyles, such as poor diet, physical inactivity, and overuse of alcohol, factors that have created near pandemics of non-communicable diseases: coronary heart disease, diabetes, cancer, and chronic lung disease. International policymakers have paid increasing attention to such issues, resulting in the 2011 United Nations High Level Meeting on Prevention and Control of NCDs and multiple follow-up resolutions within WHO, but the pandemics continue apace.

Based on its experience developing, negotiating, and implementing the FCTC, the tobacco control community has much to offer the broader NCD movement. (In fact, the FCTC is a key weapon in the NCD battle, since tobacco remains one of the leading causes of NCDs globally.)

To date, however, there has not been a serious effort to replicate the FCTC process in other areas of global health. Generally, the failure is part of a general shift away from international legal regimes and toward nonbinding public-private agreements over the past decade. The redirection is to some extent based on the notions that international legal processes in other areas failed to achieve their ultimate objectives and that nonbinding mechanisms can be effective. 

And on that score, there is still confusion about the FCTC and whether it worked. The definition of success for the FCTC has constantly evolved: first, whether countries could ever agree to a text, then what that text would include, then whether countries would ratify it, then whether its entry into force would translate into domestic policy changes, then how many lives have been saved as a result of the FCTC’s existence. As the bar has moved, the FCTC has continued to meet (at least minimum) expectations. If anything, the FCTC has proved itself to be an incredible tool for policy advocacy and advancement in many countries. 

The FCTC, as the first treaty negotiated under the auspices of WHO and the first collective response to non-communicable diseases, provides a critical case study of how developments at the international level can influence domestic policymaking and create standard regulations and norms within states. In the case of tobacco, many countries chose to conform their domestic polices to international standards and agreed to the development of a formally binding instrument in the absence of external force. There is no reason to think those results couldn’t happen again.

From the Global War on Tobacco: Mapping the World's First Public Health Treaty, by Heather Wipfli. Reprinted by permission of the publisher.

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