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FACILITATE INTERNATIONAL TOBACCO CONTROL Only 4-5 percent of the more than 1 billion people who regularly use tobacco live in the United States, whereas nearly three quarters live in developing countries.47 Economic and political factors combine to make tobacco control efforts less likely and less effective, and a U.S.-centered tobacco control policy will not reach this population. Tobacco will kill approximately 10 million people in developing countries annually by 2030, triple the present mortality rate.48 Without effective international tobacco control programs, by 2025 the number of smokers will increase 50 percent to a world total of 1.64 billion.49 Because smoking, along with AIDS, is one of the major growing causes of death worldwide,50 it is possible to avert the devastating future health toll that these projections imply only if developing countries adopt policies to reduce tobacco exposure and to prevent youths from starting to use tobacco. Diseases in developing countries are undergoing an epidemiological transition from infectious to chronic diseases. In most developed countries the epidemiological transition has been followed by a behavioral transition to unhealthy behavior, including smoking.51 In the United States and other developed nations, public health measures are designed to convince people to change their behavior and promote their health. Comprehensive tobacco control policies in other nations, such as Australia and Norway, have clearly reduced the level of tobacco use.52 One study evaluated the effects of advertising restrictions, warning labels, price, and income on tobacco consumption in 22 member countries of the Organization for Economic Cooperation and Development over 26 years and found that a combination of these measures resulted in decreased tobacco use.53 Because the transition to unhealthy behavior has not occurred in some developing countries, these countries have the opportunity to halt the tobacco epidemic before it starts. Yet tobacco control is a low priority in many developing countries, where infectious diseases and other health problems demand more immediate attention. Advocates in developing countries have limited resources to fight government-owned or heavily supported tobacco industries, which bring in significant tax revenues,54 have a strong lobbying influence, and face few advertising and marketing restrictions.55 The international tobacco control community, including 1,800 delegates from 103 countries, addressed the predicted increase in tobacco consumption among women and in developing countries at the Tenth World Conference on Tobacco or Health in Beijing, China, in August 1997. The conference approved a resolution that: Recommends governments consider the international implications of tobacco control policies or settlements with the tobacco industry, and to ensure that: such measures do not contribute to an increase in the worldwide epidemic of tobacco-related death and disease; the legal rights of those not party to any agreement or policy are fully protected; such measures do not inhibit full public scrutiny on the past, present, and future activities of the tobacco industry; and that the tobacco industry pay the costs of damage caused by tobacco.
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The United States bears a particular responsibility in the tobacco control movement because U.S. tobacco companies are major international players, producing nearly 25 percent of the cigarettes in the world export market.56 The United States cannot solve international tobacco control problems itself, but domestic tobacco policy has unavoidable international implications. The international market has become more important to tobacco firms: Cigarette exports tripled from 1984 to 1994,57 and Philip Morris's foreign sales rose from 40 percent in 1990 to 70 percent in 1996.58 Until recently, U.S. policies generally favored trade export interests over international health. The stark contrast between promoting tobacco control domestically and promoting tobacco exports risks long-term foreign policy repercussions, because foreign nations cannot help but notice the different treatment of domestic and foreign citizens. It can only intensify as the health toll rises in subsequent decades. The United States must promote, participate in, and contribute funds to the building of a capacity for evaluating and monitoring international tobacco control efforts. The success of tobacco control efforts in developed countries has largely been due to the cultivation of a receptive social and political climate through the availability of information about the real risks of tobacco use, supported by research on appropriate pricing and regulation.59 The United States can make a significant contribution to the international tobacco control effort by supporting research on the determinants of tobacco use, including the impact of advertising, promotion, and price; the extent of tobacco-related mortality; the costs of tobacco use; and disclosure of the marketing strategies that induce consumer demand. Although much of the U.S.-based research is relevant across borders, some research must be country or region specific to address the local dynamics of tobacco use. Coordination of international research and program evaluation would provide a thorough, reliable, and accessible information network comprising local studies that follow international standards, along with collaborative overviews from academia and international organizations. U.S. leadership has been powerful in the efforts to combat AIDS; comparable efforts for tobacco control are now warranted. The board believes that international tobacco control efforts should be significantly expanded both among governments and in collaboration with nongovernmental organizations. Current international monitoring is limited: The World Health Organization (WHO) allocates $60,000 and the equivalent of one full-time position to tobacco control. Special projects, country-specific activities, and additional positions are supported by approximately $500,000 in extra budgetary contributions from a few countries, including $75,000 from the United States.60 Tobacco-related research has been concentrated in developed countries and receives only $50 per 1990 tobacco-related death ($148 million-$164 million worldwide).61 Tobacco control is usually best organized at the national level because only national governments can enact most measures. Some functions, however, including monitoring and evaluation, must have an international component. WHO has a program on Tobacco OR Health. Information on that program includes background documents and a series of country summaries. WHO estimates that a strong to-
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bacco control program, with a staff of 150, including a team of experts in trade, national and international law, behavioral sciences, epidemiology, and economics,62 would demand an annual budget of $150 million.63 The World Bank has operational policies regarding tobacco use that include recommendations to client nations and has identified tobacco control as a high priority.64 The World Bank estimates that it would cost $20 million for it to mount an effective tobacco control effort.65 The International Union Against Cancer sponsors Global Link, an international tobacco control digital network. The United States should contribute toward such international efforts. The Koop-Kessler report recommended $150 million in federal funding (or equivalent amounts from settlement payments) for international tobacco control. The United States can finance the efforts of and provide expertise to countries developing tobacco control programs. Dictating tobacco control policies is both unwise and impractical. The board believes that tobacco control advocates in other countries most often simply need financial and technical support, not U.S. or international initiative, to develop and implement tobacco control programs. A number of international nongovernmental organizations have strong, established tobacco control programs, and the World Health Assembly is drafting an International Framework Convention (IFC) on Tobacco Control.66 The IFC will move nations toward the implementation of comprehensive tobacco control strategies through a series of individual protocols that will vary in degree to allow a state to be a signatory only to protocols feasible in that country. Through these protocols, the IFC will lead cooperative efforts in research and in program and policy development; share information, technology, and knowledge; meet regularly to facilitate development; address international issues; and finance tobacco control measures. The convention approach is flexible and has proven to be successful in the implementation of environmental policies. Success will depend on several agencies working to support tobacco control, including the U.S. Department of State, the U.S. Agency for International Development, the U.S. Department of Agriculture, and the office of the U.S. Trade Representative. The August 1997 Beijing World Conference on Tobacco or Health recommended the support, funding, and implementation of the IFC by all governments. The IFC is based on evidence that legislation can lay the foundation for continued research and has the potential to mobilize policy makers in various industries-including agriculture, commerce, and trade, as well as health—to support tobacco control efforts. Individual protocols could be organized by levels of comprehensiveness rather than by subject matter, allowing states to "progress from comprehensive but relatively mild tobacco control measures to a sweeping and complete comprehensive programme of tobacco control.""67 International implementation of the IFC would include the establishment of an international fund to train personnel, fund crop substitution activities, and support monitoring and evaluation of state commitments to international obligations. The United States should refrain from implementing trade policies that undermine foreign tobacco control efforts. Section 301 of the 1974 U.S. Trade Act, which "permits the U.S. Trade Representative to investigate and sanction countries whose trade practices are deemed 'unfair' to
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U.S interests,"68 has been used to facilitate the export of tobacco. When foreign practices merely protect domestic tobacco firms or a state-owned tobacco business, this policy has a reasonable trade rationale, but economic goals must be balanced against the health implications of facilitating entry of the powerful U.S. tobacco industry—with its highly sophisticated marketing and advertising methods—into a new market. A few case studies illustrate how U.S. policies can undermine public health measures abroad. In Thailand, Section 301 resulted in a compromise between trade and public health interests. Profits from the Thai Tobacco Monopoly made up a significant portion of the government's revenue, and the United States claimed that the introduction of U.S. tobacco companies was solely a trade issue.69 Thai tobacco control advocates, who had achieved a complete advertising ban in 1988, disagreed, and fought the Section 301 agreement proposed between the Thai Ministry of Finance and the United States. The issue went to the World Trade Organization, and in 1990, a General Agreement on Tariffs and Trade (GATT) panel evaluated Thai restrictions on the imports of and the internal taxes on cigarettes that Thailand maintained were necessary for public health.70 GATT found that Thailand could "give priority to human health over trade liberalization" as long as the proposed measure was "necessary."71 The panel determined that "Thailand's practice of permitting the sale of domestic cigarettes while not permitting the importation of foreign cigarettes was not 'necessary,' ''72 but that requiring foreign tobacco companies to abide by regulations that applied equally to domestic and foreign tobacco products was appropriate. The GATT decision states that restrictions on the advertising, promotion, and sale are allowable "provided they do not thereby accord treatment to imported products less favorable than that accorded to 'like' products of national origin." In Taiwan, protectionist trade practices limited foreign brands to 1 percent of the market, in part because they sold for triple the price of brands produced by the government monopoly.73 Comprehensive tobacco control programs were being developed in 1988, however, when the United States used Section 301 to open the market. Taiwan proposed retaining advertising restrictions to prevent foreign tobacco companies from targeting young people, but the United States rejected such restrictions and within two years the smoking rate among high school students increased 50 percent.74 Concerned Taiwanese health officials tried to limit U.S. promotions, but the United States claimed that the restrictions did not qualify as health measures and again threatened sanctions.75 Although Taiwan's trade practices were initially discriminatory, the introduction of U.S. tobacco products undermined public health initiatives. In Japan, Section 301 was used to place U.S. tobacco products on an even footing with domestic ones. Before the United States threatened sanctions against Japan in 1986, the Japanese government encouraged tobacco use and employed discriminatory trade practices. Japanese government policies were aimed not at tobacco control but at expanding and protecting a domestic monopoly. Japan's native tobacco industry, including the government monopoly Japan Tobacco, Inc., was protected. In the face of a 90 percent tariff, foreign brands held only 2 percent of the market.76 Once the market was opened, U.S. cigarette brands accounted for 95 percent of import sales, and within the first year they captured 10 percent of the total market.77 Even in Japan, where tobacco control efforts are minimal, the introduction of U.S. cigarettes under Section 301 had the regretta-
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ble effect of contributing to an increase in overall tobacco consumption, especially among those under age 20. The trade goal was appropriate given Japan's discriminatory trade practices and lack of antismoking health campaigns, but U.S. action, including active advertising and promotion by the U.S. firms that gained entry through U.S. government efforts, also led to increased consumption, most tellingly among youths. Adverse health impacts militate against invoking Section 301 to facilitate export of tobacco products. Even when the purpose is solely to open unfair markets in countries that have not undertaken significant measures for tobacco control, such as Japan, the health impact should be taken into account before invoking Section 301. In cases in which national governments are actively attempting to rein in tobacco use, U.S. action to facilitate the entry of U.S. tobacco products is clearly in conflict with the public health policies of the foreign governments and is even less justified. Most countries with unfair tobacco trade practices also protect other industries whose products do not have the adverse health effects of tobacco products. The U.S. Trade Representative should focus first on those products that confer trade benefits without the dire health consequences of tobacco products. A provision new to the 1998 appropriations act for the U.S. Department of Commerce directs the U.S. Trade Representative to use Section 301 for tobacco products only in very limited circumstances.78 The current administration has signaled that any tobacco-related dealings of the U.S. Trade Representative will include consultations with the Department of Health and Human Services. U.S. actions that conflict with credible tobacco control efforts in other countries are clearly inappropriate. The United States can study and learn from effective foreign tobacco control policies. The United States has the potential to influence international policy significantly. A handful of countries have been in the forefront of tobacco control for decades and are well in advance of the United States. Familiarity with their successes and failures can help predict the efficacy of proposed U.S. tobacco control measures. International data consistently indicate, for example, that in many diverse countries, price increases and bans on advertising and promotion and on smoking in public places reduce consumption.79 The international expert panel on nicotine maintenance without tobacco, cited above, is another example of how international groups can enhance tobacco control efforts. The Koop-Kessler Report notes that U.S. leadership in tobacco control is not only a domestic issue but is also a foreign policy issue.80 U.S. tobacco policy will be an important international benchmark, and it should therefore be a high one. As the home of large, multinational tobacco companies, the United States can set standards for tobacco production and marketing and can "ensure that the conduct of U.S. corporations abroad is consistent with our domestic policies and national values.81 The Koop-Kessler report recommends several principles for addressing international issues, including promoting the international adoption of U.S. standards, emphasizing public health over trade interests, funding international tobacco control activities, and preventing U.S. tobacco companies from undermining these efforts.82 It also warns that "a weak scheme of U.S. tobacco con-
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