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The Framework Convention on Tobacco Control: the Politics of Global Health Governance

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The Framework Convention on Tobacco Control: the Politics of Global Health Governance Third World Quarterly, Vol 23, No 2, pp 265–282, 2002 The framework convention on tobacco control: the politics of global health governance JEFF COLLIN, KELLEY LEE & KAREN BISSELL ABSTRACT This paper analyses the particular challenges that tobacco control poses for health governance in an era of accelerating globalisation. Tra- ditionally, health systems have been structured at the national level, and health regulation has focused on the needs of populations within individual countries. However, the increasingly global nature of the tobacco industry, and the risks it poses to public health, require a transnational approach to regulation. This has been the rationale behind negotiations for a Framework Convention on Tobacco Control (FCTC) by the Tobacco Free Initiative of the World Health Organisation (TFI/WHO). In recognition of the need to go beyond national governments, and to create a governance mechanism that can effectively address the transnational nature of the tobacco epidemic, WHO has sought to involve a broad range of interests in negotiations. The contributions of civil society groups in particular in the negotiation process have been unusual. This paper explores the nature and effectiveness of these contributions. It concludes with an assessment of whether the FCTC constitutes a significant shift towards a new form of global health gover- nance, exploring the institutional tensions inherent in attempting to extend participation within a state-centric organisation. It is estimated that some four million deaths per year can currently be attributed to tobacco, a figure representing around one in 10 adult deaths. By 2030 both the total and the proportion of tobacco-related deaths are expected to have risen dramatically, to some 10 million or one in 6 adult deaths. Such figures suggest that around 500 million people alive today will eventually be killed by tobacco. Nor will this burden be equitably shared. Smoking related deaths were once largely confined to men in high-income countries, but the marked shift in smoking patterns among high- to middle- and low-income countries will be evident in due course by rapidly rising trends in tobacco-related diseases. By 2030 70% of deaths from tobacco will occur in the developing world, up from around 50% currently ( WHO, 1999a; Jha & Chaloupka, 1999). These sobering statistics reflect a continuing struggle by the public health community to effectively address an issue that has long been understood scien- Jeff Collin, Kelley Lee and Karen Bissell all work at the Centre on Global Change and Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT. Karen Bissell also works in the Health Policy Unit of the International Union Against Tuberculosis and Lung Disease. ISSN 0143-6597 print/ISSN 1360-2241 online/02/020265-18 q 2002 Third World Quarterly DOI: 10.1080/01436590220126630 265 JEFF COLLIN ET AL tifically. Since the first wave of publications linking smoking with lung cancer around 1950 (Levin et al, 1950; Wynder & Graham, 1950; Doll & Hill, 1950), much has been learned about the diverse health impacts of tobacco consumption. Despite the clear messages emerging from medical research, however, the establishment of effective regulatory frameworks of tobacco control has been sporadic, and they remain far from adopted in most countries. The additional challenge in recent decades has been the globalisation of the tobacco industry. Globalisation is a set of processes leading to the intensification of human interaction across three types of boundaries—spatial, temporal and cognitive. The changes wrought by processes of global change are evident in many spheres of social activity, including the economic, political, cultural and technological (Lee, 2001). In terms of tobacco control, the specific challenges of globalisation are: c facilitated access to markets worldwide by the tobacco industry through trade liberalisation and specific provisions under multilateral trade agreements; c enhanced marketing, advertising and sponsorship opportunities via global communication systems; c greater economies of scale ranging from the purchase of local cigarette manufacturers, improved access to ever larger markets and the development and production of global brands; and c the ability of transnational corporations ( TNCs) to undermine the regulatory authority of national governments. It is therefore unsurprising that transnational tobacco companies ( TTCs) have enjoyed record sales and profits since the early 1990s, with the main source of growth being the developing world. While demand has gradually declined in many high-income countries thanks to changing public attitudes towards tobacco use and stronger regulation, changes in the developing world are more than compensating for contraction of traditional markets. Indeed, by expanding their presence in middle and low-income countries, TTCs will continue to remain viable and lucrative businesses in all countries This paper analyses the particular challenges that tobacco control poses for health governance in an era of accelerating globalisation. Traditionally health systems have been structured at the national level, and health regulation has focused on the needs of populations within individual countries. However, the increasingly global nature of the tobacco industry, and the risks it poses to public health, require a transnational approach to regulation. This has been the rationale behind negotiations for a Framework Convention on Tobacco Control ( FCTC) by the Tobacco Free Initiative of the World Health Organisation ( TFI/WHO). In recognition of the need to go beyond national governments, and to create a governance mechanism that can effectively address the transnational nature of tobacco issues, WHO has sought to involve a broad range of interests in negotiations. The contributions of civil society groups in particular in the negotiation process have been unusual. The paper explores the nature and effectiveness of these contributions. It concludes with an assessment of whether the FCTC constitutes a significant shift towards a new form of global health 266 FRAMEWORK CONVENTION ON TOBACCO CONTROL governance, exploring the institutional tensions inherent in attempting to extend participation within a state-centric organisation. Thwarting health governance: the tobacco industry and the limits of tobacco control Tobacco use is unlike other threats to global health. Infectious diseases do not employ multinational public relations firms. There are no front groups to promote the spread of cholera. Mosquitoes have no lobbyists. ( WHO Committee of Experts, 2000) The progress of the global epidemic of tobacco-related deaths and disease reflects the extent to which the tobacco industry has been able to thwart the development and implementation of effective tobacco control policies at national, regional and international levels. There are countries such as Canada, Australia, Thailand, Singapore and South Africa that have been able to adopt relatively comprehensive programmes of control measures, programmes that have been successful in checking or reversing increases in smoking prevalence and consumption. It is also clear that there has been a gradual spread of certain basic restrictions on issues such as advertising and youth access. The existence of a handful of beacon states and the broader profusion of limited regulation should not, however, detract attention from the inadequacies of governance in relation to tobacco. Since the release of internal industry documents following litigation in Minnesota (Ciresi et al, 1999), it has become increasingly clear that, in addition to being the primary vectors of the pandemic, TTCs have actively sought to manipulate the policy process to maintain com- mercial advantage. At the national level, tobacco companies have largely been able to manage the policy process so as to ensure that they are able to continue trading on advantageous terms and subject to limited hindrance. This is not, of course, to deny the significant variation that exists in the extent to which to health professionals, ministers and NGOs have been able to advance tobacco control objectives, with a concomitant variation in the domestic influence of the tobacco industry. A continuum of industry capacity to thwart effective tobacco control can be identified: c precluding serious consideration of tobacco control strategies; c defusing calls for legislation by the voluntary adoption of token self- regulation; c vetoing proposed legislation, or compromising its effectiveness by amend- ment; c undermining effective control measures upon implementation. At one extreme are those countries within which tobacco interests are sufficiently pervasive to have kept all but the most minimal and ineffective control measures off the policy agenda. The paucity of regulation may reflect the importance of domestic interests, particularly in the small number of national economies that are heavily dependent on tobacco production (Jha & Chaloupka, 1999). In 267 JEFF COLLIN ET AL Zimbabwe, for example, tobacco typically accounts for up to one-third of foreign currency earnings, contributes substantially to GDP and employs around 6% of the population, a context in which the close identification of government with industry and the minimal nature of existing tobacco control measures are scarcely surprising (Woelk et al, 2000). In other countries the scale of much needed investment by the major tobacco companies may be seen to carry with it
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