Framework Convention on Tobacco Control: progress and implications for health and the environment. (Guest Editorial).

The Framework Convention on Tobacco Control (FCTC) is the first international treaty ever negotiated by the member states of the World Health Organization (WHO). The final draft of the FCTC (WHO 2003) addresses a wide range of issues including price and tax measures, protection from exposure to secondhand smoke, regulation and disclosure of the contents of tobacco products, packaging and labelling, education, communication, training and public awareness, advertising, promotion and sponsorship, tobacco dependence and cessation measures, illicit trade, and sales to and by minors and liability.

Why focus on tobacco? Dramatic changes in global patterns of tobacco use and tobacco-attributable deaths and disease, and a relentless rise in the number of deaths from tobacco use provided the impetus for the WHO to take the unprecedented step of a global treaty. Although tobacco use has declined in many high-income countries, there have been sharp rises in tobacco use, especially among men, in low- and middle-incomes countries in recent decades. These increases have been fueled by falling real prices and rising incomes that have made cigarettes increasingly affordable, and by aggressive and sophisticated tobacco advertising. Close to 60% of the 5,700 billion cigarettes smoked each year and 75% of tobacco users are in developing countries (World Bank 1999; WHO 2002). This shift in the global pattern of tobacco use is reflected in the changing burden of tobacco deaths: At present, about half of the nearly 5 million deaths each year are in developing countries, but by the time the annual death toll doubles to 10 million (in two decades), 70% of the deaths will be in developing countries (Murray and Lopez 1996; WHO 2002).

Countries and development agencies are increasingly recognizing that tobacco use has negative implications for development that go beyond damage done to health outcomes and life expectancy of tobacco users and people exposed to second-hand smoke. The money that poor households spend on tobacco products (often 4 or 5% of all their disposable income) has very high opportunity costs, diverting scarce resources away from food and other basic needs. If two-thirds of the money spent on cigarettes in Bangladesh were spent on food instead, it could save more than 10 million people from malnutrition (Efroymson et al. 2001). New research in India found that tobacco use is associated with worse nutrition outcomes (Shukla 2003) and with worse child health outcomes (Shukla et al. 2002; Bonu and Rani. Personal communication 2003).

There are also negative consequences of tobacco growing: environmental degradation caused by the tobacco plant leaching nutrients from the soil, pollution from pesticides and fertilizers, deforestation as a result of the fire-curing of some common varieties of tobacco, and over a million tires accidentally caused each year by lit cigarettes and matches that cause over $27 billion dollars of damage each year (Leistikow et al. 2000). Finally, tobacco cultivation and manufacturing involve significant occupational hazards for many workers exposed to "green sickness" from handling raw tobacco, unsafe handling of pesticides, and inhalation of tobacco dust.

The final draft of the FCTC (WHO 2003) specifically touches upon issues related to the environment and to tobacco farming. The Preamble stresses the significance of the impact of tobacco use on environmental health and on the environment:

   Reflecting the concern of the international community about the
   devastating worldwide health, social, economic and environmental
   consequences of tobacco consumption and exposure to tobacco smoke.

   Recognizing that scientific evidence has unequivocally established
   that tobacco consumption and exposure to tobacco smoke cause death,
   disease and disability ....

In its main body, the final draft of the FCTC (WHO 2003) specifically addresses concerns related to the protection of the environment. Article 18 states:

   In carrying out their obligations under this Convention, the Parties
   agree to have due regard to the protection of the environment and
   the health of persons in relation to the environment in respect of
   tobacco cultivation and manufacture within their respective
   territories.

It is important to note that the WHO, the World Bank, and the final draft of the FCTC do not recommend any measures that would restrict or ban the production of tobacco leaf. Rather, they advocate strong evidence-based demand-side measures to reduce tobacco use. That is not to say that tobacco farmers and workers may not be economically vulnerable; tobacco control is only one of many determinants of the profitability of tobacco farming and manufacturing. As such, article 17 addresses the provision of support for economically viable alternative activities.

   Parties shall, in cooperation with each other and with competent
   international and regional intergovernmental organizations, promote,
   as appropriate, economically viable alternatives for tobacco
   workers, growers and, as the case may be, individual sellers.

The final draft of the FCTC (WHO 2003) contains provisions that, if implemented by countries, can have a significant impact on tobacco use and hence health outcomes. The World Bank estimated that tax increases that would raise the real price of cigarettes by 10% worldwide and a package of "non-price" measures such as advertising bans and smokefree policies would cause about 64 million of the smokers alive in 1995 to quit and would prevent at least 15 million tobacco-related deaths (Ranson et al. 2000). More recently, the WHO examined how best to reduce the health burden associated with specific risk factors such as childhood under-nutrition, cholesterol, unsafe sex, and tobacco use by reviewing the cost-effectiveness of selected interventions aimed at these risk factors. For tobacco, the WHO examined the benefits of various interventions such as taxation, advertising and sponsorship bans, smokefree policies, information provision through package labeling or counter-advertising, and cessation programmes for population health. The WHO concluded that these tobacco control policies were affordable and cost-effective in most of the subregions under study (WHO 2002). These conclusions, in light of the final draft FCTC (WHO 2003), have tremendous implications for public heath.

It is important to note that reduction in the demand for tobacco products will be gradual. Increases in global population and in incomes will attenuate the impact that strong tobacco control polices may have on the demand for tobacco products. Any slowing down of demand will likely happen gradually and will allow an equally slow process of adjustment for those most directly affected. Guindon and Boisclair (2003) projected prevalence and cigarette consumption in the future using several scenarios of changes in levels of tobacco use, as well as different assumptions about population and income growth. The results show that even if all countries immediately implement a comprehensive set of tobacco-control policies, the reduction in the number of tobacco users and in the total consumption of cigarettes will be gradual. This should give comfort to farmers and others who fear the impact of tobacco control on their livelihoods.

There are a handful of countries in the world that have already enacted and are implementing strong policies to reduce tobacco use; these countries are reaping the benefits in falling incidence of cancers, cardiovascular diseases, low birth weights and infant mortality, and other health risks associated with tobacco use. The FCTC sets new goals to encourage other countries to do the same and to work together to tackle some of the global tobacco issues, notably smuggling and cross-border advertising. There are very strong vested interests that have tried to undermine support for the FCTC by blatantly misrepresenting the intent, provisions, and likely consequences of the treaty to farmers, workers, politicians, and others in governments around the world, just as they have sought to derail and subvert national tobacco control policies. There is still much to be done to ensure that tobacco policies are based on evidence and facts, not on fearmongering, and are designed to protect public health, not private profits.

G. Emmanuel Guindon

World Health Organization

Geneva, Switzerland

E-mail: [e-mail]

Joy de Beyer

World Bank

Washington DC, USA

Sarah Galbraith

World Health Organization

Geneva, Switzerland

REFERENCES

Efroymson DS, Ahmed S, Townsend J, Alam SM, Dey AR, Saha R, et al. 2001. Hungry for tobacco: en analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tob Control 10:212-217. Available: http://tc.bmjjournals.com/cgi/content/ full/10/3/212 [accessed 7 April 2003].

Guindon GE, Boisclair D. 2003. Past, Current and Future Trends in Tobacco Use. HNP Discussion Paper. Economics of Tobacco Control Paper No, 6, Washington, DC:World Bank

Leistikow BN, Martin DC, Milano CE. 2000. Fire injuries, disasters, and costs from cigarettes and cigarette tights: a global overview. Prev Med 31:91-99.

Murray CJL, Lopez AD. 1996. Assessing the burden of disease that can be attributed to specific rick factors. In: Ad Hoc Committee on Health Research Relating to Future Intervention Options. Investing in Health Research and Development. Geneva:World Health Organization, 187-194.

Ranson K, Jha P, Chaloupka FJ, Nguyen S. 2000. The effectiveness and cost-effectiveness of price increases and other tobacco-control policies. In: Tobacco Control in Developing Countries (Jha P, Chaloupka FJ, eds). New York:Oxford University Press, 427-447.

Shukla HC, Gupta PC, Mehta HC, Hebert JR. 2002. Descriptive epidemiology of body mass index of an urban adult population in western India. J Epidemiol Community Health 56(11):876-880.

Shukla HC, Gupta PC, Pednekar M, Hebert JR 2003. Tobacco use: an independent risk factor for poor nutrition. Implications for publics health in India. In: Tobacco Research in India: Proceedings of en Expert Meeting on Supporting Efforts to Reduce Harm. 10-11 April 2002, New Delhi, India. Atlanta, GA:Centers for Disease Control and Prevention/Office on Smoking and Health.

The World Bank. 1999. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Development in Practice Series. Washington, DC:The World Bank. Available: http://wwwl.worldbank.org/tobacco/book/pdf/tobacco.pdf [accessed 7 April 2003].

WHO. 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva:World Health Organization. Available: http://www.who.int/whr/2002/en/ [accessed 7 April 2003].

WHO. 2003. Draft WHO Framework Convention on Tobacco Control. A/FCTC/INB6/5. Available: http://www.who.int/gb/fctc/PDF/inb6/einb65.pdf [accessed 3 April 2003].

G. Emmanud Guindon is an economist at the Tobacco Free Initiative of the World Heahh Organization in Geneva. Joy de Beyer is an economist who coordinates tobacco control work at the World Bank. Sarah Galbraith is a legal officer with the Tobacco Free Initiative of the World Health Organization in Geneva.