Tobacco Control

The WHO Framework Convention on Tobacco Control, An Urgent Call for U.S. Ratification – Alcohol, Drug, and Tobacco Study Group (ADTSG)

 Overview of the problem & Revised Statement

Mimi Nichter, Chair; Mac Marshall; Roland Moore; Mark Nichter, Nathaniel Wander

The commercial production and promotion of tobacco constitutes a global problem. Each year, approximately five million people die from tobacco-related diseases. Tobacco-induced diseases kill one-half of all lifetime users. In terms of its significance in international health, tobacco-induced diseases kill more people worldwide than malaria, maternal and major childhood conditions, and tuberculosis combined. By 2030, the annual number of deaths caused by tobacco is projected to rise to 10 million, with half of these deaths occurring among the 35 to 69 year old age group. As a consequence, smoking will cause one-third of all deaths globally in the next 20 years. The majority of these deaths will occur in low income countries.

Beyond statistics, it is important to consider that tobacco-related illnesses have a devastating impact not only on the smoker but also on the smoker’s family members. In most low income countries, where men are often the primary source of income, it is usually the men who are smokers, leaving the wife and children to care for a male household member during his extended illness. Tobacco use is highest among the poor in almost all countries and as a result, the poor bear most of the economic and disease burden of tobacco use. For example, recent studies in Bangladesh have found that the poorest households spend far more on tobacco than on food, health, and education, and similar findings have been reported for China, Vietnam, India and Egypt. Beyond the devastation of poor families, serious environmental costs are associated with tobacco production, especially deforestation, erosion and desertification.

As tobacco consumption rates have declined in many western countries, the tobacco industry increasingly has targeted its deadly products and deceptive marketing at low and low-middle income countries. Multinational tobacco companies have strengthened their presence in low income countries by engaging in their economies and communities. Seemingly philanthropic acts of building schools and hospitals, providing scholarships to medical students, and funding community events have allowed the tobacco companies to buy into health, education, and civic sectors of society. Poorer nations are less likely to resist such financial aid and often look favorably on the tobacco industry, which offers money with few visible strings attached.

As the world’s largest advertiser, the tobacco industry has been able to block tobacco advertising bans and restrictions across the globe. In addition, the tobacco industry employs a variety of tactics to maneuver around the bans and restrictions that do exist. For example, Philip Morris and RJ Reynolds have used a strategy in Asia called “brand-stretching,” in which they put their brand names on clothing lines and then advertise the clothing through a variety of media, including television. This allows them to achieve brand recognition, while skirting the restrictions that prohibit them from directly advertising cigarettes. The tobacco companies also market their brands by sponsoring sporting events, disco parties, and concerts where free cigarette giveaways are prominent.

Controlling the Industry: The Framework Convention on Tobacco Control

Created under the auspices of the World Health Organization, The Framework Convention on Tobacco Control (FCTC) is the first-ever global health treaty. The objective of the FCTC is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.” It provides the basic tools for countries to enact comprehensive tobacco control legislation and take on the powerful tobacco industry.

On February 27, 2005, after four years of intensive negotiations, the FCTC became international law. To date, the FCTC has been ratified by 140 countries, including China, the world’s largest grower and biggest consumer of tobacco, and other major tobacco-producing and consuming nations such as India, Japan, and Mexico. Indeed, it is the most rapidly embraced treaty in history, covering more than three-fourths of the world’s population.

The mandatory provisions of the FCTC include:
  • A comprehensive ban on advertising, sponsorship, and promotion, with narrow exceptions for countries such as the U.S. that face constitutional conflicts
  • Warning labels that cover at least 30% of the package
  • Elimination of deceptive and misleading labels such as “light” and “low tar”
  • Protection of non-smokers in public places and places of work
  • Specific measures to reduce tobacco smuggling
The treaty also encourages parties to enact other tobacco control policies, such as:
  • Increasing tobacco taxes
  • Eliminating duty-free sales of tobacco products
  • Considering litigation against the tobacco industry
  • Prohibiting the sale of tobacco to minors
  • Including tobacco cessation services in national health plans

What is the U.S. position on the FCTC? Although the U.S. signed the treaty in 2004, to date it has not been ratified (see note below). Administration spokespeople claim that they support the treaty and want to see it ratified but the treaty has languished at the State Department, where it is still “under review.” The administration reaped benefits by signing in an election year, but apparently it has little intention of asking the Senate to vote on the treaty. In President Bush’s view, the treaty interferes with U.S. economic interests.

Indeed, the Bush administration has close ties to the tobacco industry, and the U.S. played a destructive role in the FCTC negotiations, attempting to weaken almost every provision of the treaty and supporting positions consistent with those of the tobacco industry. Delegates to the negotiations reported that the U.S. threatened to withhold monetary and technical assistance to tobacco control efforts if its positions were not adopted. The developing nation delegates, however, did not acquiesce to the U.S. threats, and a strong treaty ultimately was negotiated.

The mere signing of the treaty without ratification commits countries to support it, but does not create a legal obligation to abide by its provisions. Thus, the U.S. signing of the treaty has been viewed by many as a public relations move which does little to protect people nationally or internationally from the harm of tobacco.

Why Should the SMA Urge Ratification of the Treaty by the U.S.?

The Society for Medical Anthropology urges ratification of the treaty by the U.S. Support of its effective implementation domestically and internationally would enable the U.S. to become a leader in protecting public health around the world. It would send a strong message that our country is ready to take action to turn the tide of the global tobacco epidemic rather than appearing to be under the wing of Big Tobacco. That the United States, the wealthiest and most powerful country in the world, is not involved in the fight to help save lives through controls on tobacco is unacceptable.

Many national organizations have called for the U.S. to ratify the treaty including the American Cancer Society, American Heart Association, American Lung Association, Action on Smoking and Health, Campaign for Tobacco-Free Kids, Corporate Accountability International, Essential Action, and Faith United Against Tobacco, among others.

As an organization and as individuals, each of us can take action by emailing, faxing, or calling our state’s two senators, and our congressional representative, asking them to persuade the U.S. government to ratify the FCTC.

We can also write letters to the editor of local and national newspapers, thus keeping the issue alive and urging a wider readership to put pressure on their elected officials to ratify the FCTC.

What can we do as medical anthropologists?

Many of us conduct research in countries where the FCTC has been ratified and where implementation of the treaty is already underway. We need to be involved in monitoring this implementation process. We can do so by monitoring (1) the successes in terms of how the treaty is implemented (e.g., whether advertising bans are enforced (e.g., brand logos which used to be on the marquis of many small shops in India have largely been removed); (2) how the industry is bending the rules (e.g., engaging in brand stretching—like opening up shops which have the name “Camel” and selling Camel brand jeans, etc.); (3) the emergence of new products which give the illusion of safety, (4) whether the industry is targeting young adults through “cigarette giveaways” in bars and clubs; and (5) the emergence of new market sectors with products specifically made to appeal to women (e.g., in Asia and other regions where women traditionally do not smoke).

Research can also be undertaken in those countries that have not ratified the treaty to collect and monitor data on the activities of the tobacco industry and reasons why signing/ratifying the treaty is problematic. In the U.S., researchers might explore the public’s awareness of the treaty and layperson’s understanding of role of the U.S. in the spread of global tobacco and the ramifications of these practices on global health.

Resource Materials:

  • Framework Convention Alliance for Tobacco Control:
  • World Health Organization web pages on the FCTC:
  • FCTC Now! Activist site:
  • Campaign for Tobacco-Free Kids.
  • Corporate Accountability International
  • (this takes you an email-ready letter for Secretary of State Condoleezza Rice and President Bush demanding that the U.S. ratify the FCTC)
  • Resources on Global Tobacco:
  • Ezzati, M. & Lopez, A.D. 2003. Estimates of global mortality attributable to smoking in 2000. Lancet. 362:847-852.
  • Efroymson D., Ahmed, S., Townsend, J., Alam, A.M., Dey, A.R., Saha, R., et al. 2001. Hungry for tobacco: an analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tobacco Control 10:212-217.
  • Geist H. J. 1999. Global Assessment of Deforestation Related to Tobacco Farming. Tobacco Control, 8:18-28.
  • Kaufman, N. and Nichter, Mimi. 2001.The marketing of tobacco to women: Global perspectives. In J.M. Samet and S.Y. Soon (Eds.) Women and the Tobacco Epidemic: Challenges for the 21st Century. Geneva: World Health Organization.
  • The World Bank, 1999. Curbing the epidemic: Governments and the economics of tobacco control. Washington D.C.: The World Bank.
  • Wander N, Malone RE. Making Big Tobacco Give In: You Lose, They Win. Published Ahead of Print on October 3, 2006, as 10.2105/AJPH.2005.075119
  • American Journal of Public Health, November 2006.
  • note: The U.S. has a long history of refusing to ratify international treaties. Treaties that the U.S. has signed and not ratified include: the Convention on the Rights of Children, the Convention on Biological Diversity, and the Persistent Organic Pollutants treaty.