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 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-