Special Theme – Tobacco WHO Framework Convention on Tobacco Control: a global ‘‘good’’ for public health Allyn L. Taylor1 & Douglas W. Bettcher2

Although the application of legal instruments to international health issues — relative to other areas of international concern — is still at a rudimentary stage of development, the transnational health impacts of globalization provide a rationale for the codification and implementation of global norms to deal with shared problems. The experience of promulgating international agreements in other areas closely related to international health — the environment, for example — demonstrates how evidence-based international agreements can effectively address a range of problems that cross national boundaries. The framework convention-protocol approach is a legally binding, incremental approach to international law-making that has frequently been employed to deal with environmental threats, and is now being adapted to serve purely public health ends. Experience with the recently initiated WHO Framework Convention on Tobacco Control provides a case study of how transnational public health problems can be addressed by an international legal approach. Scientific evidence in public health and economics has provided the foundation for the elaboration of this evidence-based strategy. The present tobacco epidemic poses a range of transnational challenges that are best addressed through coordinated action. In this article, it is argued that the proposed Convention has the potential to be a global ‘‘good’’ for public health — i.e. it has the potential to yield important global public health benefits — and that it represents a test case for more active involvement of the public health community in international law-making.

Keywords: commerce; international cooperation; legislation, health; tobacco industry; treaties; smoking, epidemiology.

Voir page 927 le re´sume´ en franc¸ais. En la pa´ gina 928 figura un resumen en espan˜ ol.

Introduction opportunities for promoting health (3). Consequently, the codification and implementation of binding health The health of populations in all parts of the world is norms is becoming increasingly important as inter- increasingly being influenced by transnational eco- national health interdependence accelerates and nomic, social, scientific, technological and cultural nations recognize the need for cooperation to solve forces. Consequently, the domestic and international essential problems (4). The health impacts of spheres of health policy are becoming more and more globalization, both positive and negative, have become intertwined and inseparable (1, 2). As an example of a key policy issue leading to an expansion of how such transnational problems can be addressed conventional international law-making (5). by an international legal approach, this article International health law now encompasses presents a case study of the WHO Framework increasingly complex concerns, including aspects of Convention on Tobacco Control, which was initiated human reproduction and human cloning, human recently to combat the globalized tobacco epidemic. organ transplantation, emerging infectious diseases, The planetary context of development has international food trade, control of the safety of profound global implications for public health, and, pharmaceuticals, and control of addictive substances concomitantly, the expansion and application of such as narcotics. As a result of the new global international health law. Although the protection and impacts, international health law is recognized as promotion of public health have traditionally been inextricably linked to other areas of international legal viewed as matters of national concern, the rapid and concern, such as international environmental law and widespread influence of globalization calls for new the control of toxic pollutants, international labour frameworks of international collaboration to deal with law and occupational health and safety, arms control the emerging global threats to health and to create and the banning of weapons of mass destruction, nuclear safety and radiation protection, and fertility and population growth (6). Moreover, in the 1 Adviser, Tobacco Free Initiative, World Health Organization, development of international legal instruments — Geneva, Switzerland; and Adjunct Assistant Professor, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD, USA. for example, to address transboundary and global 2 Coordinator, FCTC Team, Tobacco Free Initiative, World Health environmental problems — scientific evidence has Organization, 1211 Geneva 27, Switzerland (email: bettcherd been an important component of the treaty-making @who.int). Correspondence should be addressed to this author. process. Ref. No. 00-0631

920 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (7) WHO Framework Convention on Tobacco Control

Despite the evolution of international law- globalization for public health are negative. Many making in health and related areas of international transnational health threats could be turned into concern during the last few decades under the opportunities for improving our global public health auspices of numerous organizations and agencies of futures. the United Nations system, WHO has never — until For example, the globalization of modern recently — utilized its constitutional authority to information technologies carries the risk of advan- promote the development of a binding international cing the worldwide trade and consumption of convention in any field of global public health. Thus, harmful commodities, such as tobacco. At the same it was only in May 1999 that the Member States of time, however, if modern information technologies WHO adopted a resolution that accelerated the become accessible and affordable to developing process for negotiating and adopting the Organiza- countries, the potential benefits are extensive — tion’s first treaty, the WHO Framework Convention including telemedicine, interactive health networks, on Tobacco Control. communication services between health workers, Why is the development of international law and distance learning (8). As a further example, the important to public health at the present time? This globalization of advances in biomedical science raises article addresses this question in three ways. the possibility of genetics-based discrimination by the . First, it is argued that the current globalization of public and private sectors in all countries with access public health problems provides a context in to the new technology in genetics. However, which the development of global norms and advances in genetics can also lead to dramatic standards becomes increasingly necessary. progress against diseases in both rich and poor . Second, the experience of elaborating interna- countries, provided that these technologies become tional agreements in other areas closely related to available and affordable worldwide (9). international health, particularly environmental In the context of the ongoing public health matters, demonstrates how international agree- debate on globalization, this article addresses the ments can make an impact and how scientific particular relevance of the WHO Convention to the evidence has been employed to support the globalization of the tobacco epidemic. development of international law. . Finally, the experience in negotiating the WHO Public benefits in a globalized world Convention provides a case study of how The growing number of public health concerns that transnational public health problems can be are bypassing or spilling over national boundaries has addressed by an international approach, and also ushered in a new era of global public health policy. how scientific evidence in both public health and Although there is a long history of multilateral economics provided a foundation for the devel- cooperation in some limited areas of public health opment of binding global agreements. policy, particularly infectious diseases (10, 11), public health has traditionally been viewed as being almost exclusively a national concern. However, with global International norms: what are integration has come a paradigm shift in which the global public health benefits? public health is now being recognized not only as a topic of global concern, but also as a global public Globalization of public health ‘‘good’’ (12, 13). Globalization — the process of increasing economic, At the national level the concept of public political and social interdependence, which takes ‘‘goods’’ has long been an integral part of economic place as capital, traded goods, persons, concepts, theory, with its roots in 18th-century scholarship. images, ideas and values diffuse across national ‘‘Public goods are essentially defined by the existence boundaries — is occurring at ever increasing rates (7). of a provision problem; by their nature they cannot The roots of globalization can be traced back to the easily be provided by the ‘‘invisible hand’’ of the industrial revolution and the laissez-faire economic market and therefore require government to over- policies of the late 19th century. However, the come the failures of the market in order to achieve globalization of the late 20th century is assuming a efficient allocation of essential resources’’ (14). magnitude — and taking on patterns — unprece- Depending upon the political structure of particular dented in world history (1). governments, ‘‘goods’’ conventionally falling within Globalization includes many interconnected the public category include providing national risks and phenomena that affect the sustainability of defence and police services, administering justice health systems and the well-being of populations in and enforcing private property rights, organizing rich and poor countries alike. Recently, Yach & public transportation, protecting the environment, Bettcher identified many of the health-related and promoting public health. features of global change (1) and observed that the With ever expanding multilateral interdepen- negative health repercussions associated with in- dence and integration, many policy questions that creasing global interdependence — for example, in were once considered purely national issues or international trade and communication and financial national public goods have now transcended national liberalization — cannot be overlooked. However, it boundaries, as they cannot be addressed by unilateral should not be assumed that all the implications of

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domestic action. Domestic policy goals, such as legal foundation for many other intermediate products financial stability, human security and the preserva- with global public benefits, including research, tion of culture, are more and more subject to surveillance, technical assistance programmes, and international forces. Consequently, in recent years information clearing-houses. In addition, institutional the international aspects of public goods have mechanisms often established in international agree- received much attention. ments — such as compulsory meetings of the parties, Inge et al. have developed a useful typology of and monitoring or supervising compliance and the global public goods: ‘‘At a minimum, a global public international infrastructure — contribute towards the good would meet the following criteria: its benefits provision of final global public goods (14). extend to more than one group of countries and do not discriminate against any population group or any set of generations, present or future’’ (14). The impact of international law Global public goods can also be sorted as and the role of science intermediate global public goods and final global public goods. The role of scientific evidence in . ‘‘Intermediate global public goods, such as international law-making international regimes, contribute towards the As part of a science-based discipline, public health provision of final global public goods’’ (14). experts and policy-makers are increasingly demand- . ‘‘Final global public goods are outcomes rather ing that the rationale for a particular intervention than ‘‘goods’’ in the standard sense. They may be should be based on evidence. We demonstrate in this tangible (such as the environment, or the common section how these principles can apply also to heritage of mankind) or intangible (such as peace international legal interventions. The development or financial stability)’’ (14). and implementation of recent environmental agree- ments are closely linked to the accumulation of Particularly noteworthy is the growing recognition that scientific evidence, and to the scientific under- many issues directly related to public health are global standing of the environmental system. Evidence- public goods. Controlling the spread of emerging based environmental treaties provide an important infectious diseases, expanding the access to benefits of template for the elaboration of legal agreements, such biotechnology, enhancing food security, and prevent- as the WHO Convention, to be developed under the ing further environmental degradation are all global umbrella of the public health community. public health goods (13–15). The framework convention-protocol approach has been applied extensively in international environ- International legal agreements: global mental law. This approach allows for the addition of public benefits protocols and annexes to the basic framework as Since there is no supra-national authority that can improved scientific understanding is reached (17) provide global public goods, the implications of and/or as political consensus for concrete action globalization include the need for greater intersectoral develops (16). This approach to international law- action and transnational cooperation and partnerships. making consists of at least two components: It is widely recognized that there is ‘‘broad justification – a framework convention, which typically estab- for a more systematic and integrated approach to lishes a general consensus about the relevant facts, international cooperation’’ as ‘‘improving international broad international standards, and an institutional cooperation will strengthen the capacity of national structure for global governance; governments to achieve their national policy objec- – protocols that supplement, clarify, amend, or tives’’ (15). A central component of enhanced multi- qualify a framework convention and usually set lateral cooperation in support of final global public forth more specific commitments or added goods is the expanded use of international instru- institutional arrangements. ments, including conventional international law. In order to obtain national objectives for the Risk assessment has been an important analytical tool protection and promotion of public health, govern- in determining the magnitude of transboundary ments must increasingly turn to international co- environmental risks. For example, the protocols to operation to achieve some control over the the Convention on Long Range Transboundary Air transboundary forces that affect their populations. Pollution concerning sulfur emissions, nitrogen As described below, many areas relevant to global oxides, volatile compounds, and heavy metals and public health show evidence for the expanded use of persistent pollutants were supported by scientific international law and international institutions — evidence. Moreover, the political decision to negotiate typically established under international agreements global norms to address depletion of the ozone layer — as intermediate global public goods to promote or was heavily influenced by an increasing body of achieve a final global public health good. scientific evidence that started to accumulate data in International legal agreements — or treaties — the late 1970s and early 1980s. The ozone depletion are among the most important intermediate public theory linked emissions of chlorofluorocarbons health goods (16). International agreements provide a (CFCs) — through release of chlorine into the stratosphere — to a significant depletion of the ozone

922 Bulletin of the World Health Organization, 2000, 78 (7) WHO Framework Convention on Tobacco Control layer. Later research linked depletion of the ozone consensus a resolution (WHA52.18), which paved layer to an increased incidence of skin cancer in light- the way for starting multilateral negotiations on the skinned populations, an increased incidence of WHO Framework Convention on Tobacco Control cataracts, and a weakening of the immune system and possible related protocol agreements (21). A (18). Likewise, in 1990, a Working Group established record 50 countries took the floor to pledge financial by the Intergovernmental Panel on Climate Change and political support for the WHO Convention. The issued a report entitled the Science of climate change, which list included the five permanent members of the UN helped to push forward the negotiation process for the Security Council, major tobacco growers and Framework Convention on Climate Change (19). exporters, as well as several developing and devel- oped countries that face the brunt of the tobacco Do international legal agreements industry’s marketing and promotion. make a difference? Annexed to this resolution is a detailed outline It is generally accepted in public health that, for an of expected activities for the development of the intervention to be useful, it must have a proven WHO Convention, which is divided into two stages. impact. The experience of some of the environmental . A technical Working Group, open to all Member agreements provides useful insights regarding the States, meeting in two sessions in 1999 and 2000 beneficial impacts of international legal instruments. (between the 52nd and 53rd World Health Whenstatesagreetobelegallyboundbythe Assemblies), to prepare ‘‘proposed draft ele- obligations contained in an international agreement, ments’’ of the WHO Convention. a measure of the agreement’s effectiveness is . An Intergovernmental Negotiating Body, open to determined by the extent to which it causes the states all Member States, to ‘‘draft and negotiate the to alter their behaviour in line with the national proposed FCTC and possible related protocols.’’ obligations contained in the treaty (20). International organizations have been able, in some cases, to serve as In the annexed outline, the target date for the effective law-making platforms for nations in matters adoption of the WHO Convention and possible related to the environment and human health. related protocols was set for May 2003, which gives The global commitments to curb ozone the Intergovernmental Negotiating Body three years depletion provide an example of a particularly to complete its work (22). effective international legal agreement. The scientific findings described above led in the mid-1980s to the The globalization of the tobacco epidemic negotiation and adoption of a legal instrument Current situation. Use of tobacco is one of the major consisting of the Vienna Convention for the public health disasters of the 20th century (23). There Protection of the Ozone Layer (a framework are over 1.25 billion smokers (250 million females, convention containing only general obligations) and 1 billion males) in the world today, representing one- the Montreal Ozone Protocol, which contains more third of the world’s population aged 515 years (24). specific commitments and institutional arrange- Cigarette smoking is one of the largest causes of ments. As a result, in part of the codification and preventable death worldwide and the leading cause of implementation of the Vienna Convention, Montreal premature death in industrialized countries. Cur- Protocol and the London Amendments thereto, the rently, cigarette smoking and other forms of tobacco global consumption of CFCs between 1986 and 1996 consumption kill four million people per year, with declined by more than 70%, from 1.1 million tonnes the majority of these deaths already occurring in worldwide to 160 000 tonnes. developing nations. Moreover, the epidemic of The agreement and effective collaboration by tobacco addiction, disease and death is continuing the international community to reduce CFC levels to shift rapidly to the developing and transitional qualifies as an intermediate global public good, in that market countries (25, 26). this international legal instrument is contributing Today the majority of smokers live in devel- towards the attainment of a final global public good, oping countries (800 million); most are men namely the attainment of an intact ozone shield (14). (700 million) and 300 million are Chinese. At current The principle of international environmental legal levels of consumption, the tobacco epidemic is regimes as intermediate public goods provides a expected to kill up to 8.4 million people per year by template for global social action by the public health 2020, with 70% of these deaths occurring in community. This approach will be elaborated further developing countries (27). Hence, if unchecked, in the next section. within the next 30 years tobacco use will be the leading cause of premature death worldwide. Smoking has been associated, inter alia, with an Case study: the Framework increased risk of not only several different cancers, including lung and bladder cancer, but also ischaemic Convention on Tobacco Control heart disease, bronchitis and emphysema, and In May 1999, the World Health Assembly — the increased antenatal and perinatal mortality. The governing body of the World Health Organization, health effects of tobacco consumption have strong comprising 191 Member States — adopted by public links because forced or passive smoking

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presents health risks to non-smokers and the China (Province of Taiwan), Japan, and the Republic financial costs of treating tobacco-related diseases of Korea, have also facilitated market penetration in are borne by tax payers in countries where health care developing countries (34). is provided by the public sector. In industrialized Trade liberalization and market penetration countries alone, smoking-related health care ac- have been linked to a greater risk of increased tobacco counts for 6–15% of all annual health care costs (28). consumption, particularly in low- and middle-income A distinctive feature of the globalization of the countries. A recent study has empirically examined tobacco pandemic is the role of multinational the relationship between cigarette consumption and corporations (29). Since the beginning of the 20th global trade in tobacco products (32). Estimates from century, a few major corporations have controlled this study indicate that reduced trade barriers have much of the world’s cigarette market. Today the world had a large and significant impact on cigarette market for tobacco is dominated by a handful of consumption in low-income countries and a small American, British and Japanese multinational con- but significant impact in middle-income countries. glomerates, which have a controlling presence not only Other aspects. In addition to trade liberal- in western countries but also throughout the devel- ization, the transnational tobacco industry has also oping world. China stands out as an exception, with its taken advantage of direct forms of market penetra- large production of tobacco products mainly used in tion in cash-hungry governments of poor countries the domestic market. As Asma et al. have observed, via direct foreign investment, by either licensing with understanding the history and conduct of the tobacco a domestic monopoly in joint ventures, or other industry is central to the development of guiding strategic partnering with domestic companies (35). strategies for tobacco control (23). However, the globalization of the tobacco pandemic A significant contributor to the increased risk of is not limited to international trade and investment. tobacco-related diseases worldwide is the globalization The epidemic is being spread and reinforced of the tobacco epidemic through the successful efforts worldwide through a complex mix of factors, of the tobacco industry to expand their global trade including trade liberalization, global marketing and and to achieve market penetration in developing communications, and direct foreign investment countries and transitional market economies (30–32). (23, 28). Processes and practices that transcend Major transnational tobacco companies targeted national boundaries are fueling numerous aspects growing markets in Latin America in the 1960s, the of the tobacco epidemic. For example, an estimated newly industrializing economies of Asia (Japan, the 355 billion cigarettes (33% of the world market for Republic of Korea, China (Province of Taiwan), and exported cigarettes) are smuggled each year in order Thailand) in the 1980s, and — in the 1990s and to avoid taxes (36). As one authority has noted, currently — have moved into Africa, China, and ‘‘cigarette smuggling is now so widespread and well eastern Europe, and are increasingly targeting young organized that it poses a serious threat to both public persons and women (33). health and government treasuries, which are losing International trade liberalization. The global thousands of millions of dollars in revenue’’ (36). As a reach of the transnational tobacco industry has been further example, tobacco advertising and sponsor- enhanced by the recent wave of international trade ship contributes to the global spread of tobacco use liberalization, particularly the Uruguay Round of trade through the worldwide media, such as cable and negotiations, which included for the first time, the satellite television, the Internet, and sponsorship liberalization of unmanufactured tobacco (30, 32). of worldwide sports and entertainment events. In The Uruguay Round, which was concluded in 1994, the USA alone, the tobacco industry spent established the World Trade Organization (WTO) and US$ 5.66 billion on advertising and promotion in brought about an overhaul of the international trade 1997 (37), with approximately 90% of this being on regime by the conclusion of a number of new product promotion. Although global advertising and multilateral agreements addressing contemporary promotion of tobacco products is substantial, there trade issues, including tobacco. These new WTO are currently no figures on the exact amount the multilateral agreements have facilitated the expansion tobacco industry spends worldwide. of trade in tobacco products through significant As the vector of the tobacco epidemic, the reductions in tariff and non-tariff barriers to trade. tobacco industry is well aware of the characteristics of Regional trade agreements and associations, such as globalization and is attempting to manipulate the North American Free Trade Agreement, the globalization trends in its favour. Recently released European Union, the Association of South-East Asian documents of the multinational tobacco industry Nations, the Common Market of East and Southern concretely indicate that the industry ‘‘plans, develops African, the Common Market of Western African and operates its markets on a global scale’’ (38). For States, and the Organization of American States, have example, a careful review of tobacco industry acted in synergy with the global level by mandating documents has shown that the industry looks further trade liberalization in goods and services, towards the creation of new ‘‘global brands’’ and a including tobacco, at the regional level. Furthermore, ‘‘global smoker’’ as one way of overcoming markets bilateral trade agreements, such as those negotiated in which have thus far resisted the tobacco industry’s the 1980s by the US Trade Representative under onslaught: Section 301 of the revised 1974 US Trade Act with

924 Bulletin of the World Health Organization, 2000, 78 (7) WHO Framework Convention on Tobacco Control

‘‘[G]lobalisation has its limits. In India, for advance national and international efforts to curb the instance, around 80 per cent of the population uses growth of the pandemic (23). The WHO Working traditional tobacco products such as bidis or chewing Group, which is the intergovernmental technical tobacco ... . For how long will these markets resist the body established to elaborate the scientific and policy attraction of global trends? In one or two generations, foundation for the WHO Convention and possible the sons and the grandsons of today’s Indians may related protocols, agreed at its first meeting in not want to smoke bidis or chew pan masala. Global October 1999 that substantive tobacco control brands are one way to accelerate this process’’ (29). obligations in the Convention and related protocols The public release of over 35 million pages of should focus principally on empirically established documents in 1998 from the internal files of the demand reduction strategies (42). Hence, the Work- tobacco industry through the landmark lawsuit ing Group emphasized that the WHO Convention brought against the tobacco industry by the Attorney and possible related protocols should promote global General of Minnesota and Blue Cross and Blue Shield agreement and cooperation on the primary interven- of Minnesota clearly demonstrates the global threat tions on which there is overwhelming empirical which the industry poses for tobacco control efforts: support, including tobacco taxes and prices, adver- ‘‘The documents disclosed in the last few years tising and promotion, mass media and counter- — the words of the industry itself — are the best advertising, warning labels, clean indoor air policies, proof of its fraud regarding (i) what the industry knew and treatment of tobacco dependence. Consistent — that smoking causes cancer, (ii) when the industry with the World Bank’s recommendations, the Work- knew it — in the 1950s, and (iii) what the industry did ing Group supported coordinated action against about it — systematic denial and cover-up’’ (39). smuggling as the one key supply-side area for global The dramatic increase in tobacco consumption agreement and harmonization of strategies. in the last couple of decades portends public health While a number of studies have quantified the and economic tragedy for nations worldwide in the impact of tobacco price and tax increases on reducing 21st century. Much of the potential calamity can be tobacco consumption, establishing the precise im- averted, however, through effective implementation pact of other demand reduction strategies has been of tobacco control strategies. In its recent report, more difficult. Overall, the demand reduction Curbing the epidemic: governments and the economics of tobacco strategies emphasized by the Working Group are control, the World Bank concluded that tobacco consistent with the recommendations of the World control is highly cost-effective as part of a basic Bank. According to the World Bank, the potential public health package in all countries (28). combined impact of non-price tobacco control Global tobacco control has significant charac- measures, including information for consumers, teristics for global public good. Traditionally, preven- dissemination of scientific reports and research, tion or treatment of noncommunicable diseases was warning labels, counter-advertising, comprehensive considered to be mostly a private good, since the risk bans on advertising and promotion, and clean indoor factors associated with such diseases, including use of air polices, would be to persuade 2–10% of tobacco, are related to individual choices in lifestyle. consumers to quit smoking. Based on these assump- However, globalization has blurred the traditional line tions, a package of non-price measures could reduce between private and public in health and brought the number of smokers alive in 1995 by 23 million international tobacco control efforts within the worldwide (28). The evidence base for strategies domain of global public goods (13). advanced by the Working Group are discussed in Since many, if not all, of the challenges of detail by Joossens elsewhere in this issue of the tobacco control are increasingly transcending na- Bulletin (41). tional boundaries, stemming the growth of the At its second session in March 2000, the tobacco pandemic requires global agreement and Working Group prepared a final report for the action. The globalization of the tobacco pandemic 53rd World Health Assembly. After considering this restricts the capacity of countries to unilaterally report, the World Health Assembly adopted Resolu- control tobacco within their sovereign borders (40). tion WHA53.16, which formally set in motion the All transnational tobacco control issues — including negotiation process, which is due to commence in trade, smuggling, advertising and sponsorship, prices October 2000 with the first session of the Inter- and taxes, control of toxic substances, and tobacco governmental Negotiating Body. Working from package design and labelling require multilateral WHO Secretariat papers that analysed the potential cooperation and effective action at the global level elements of the WHO Convention, based largely on (41). If not attended to, these global aspects of the examples of existing framework conventions and tobacco control can overwhelm the best national other treaties (43, 44), both sessions of the Working tobacco control strategies. Group examined: (i) other potential national obliga- tions under the WHO Convention, such as educa- An international evidence-based approach tion, training and public awareness, cooperation in The WHO Convention is being developed as a surveillance, cooperation in scientific research, and scientific, evidence-based approach to global tobacco exchange of information; (ii) the institutions that control, which has the potential to significantly might be established under the Convention, such as a conference of the parties and the Secretariat, a

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financial mechanism, a subsidiary body for science, standards ultimately codified in the Convention can and a subsidiary body for implementation; (iii) legally establish global priorities for national action implementation mechanisms, such as for national and multilateral cooperation on tobacco control. The reporting and dispute settlements; (iv) procedures for institutions eventually established by the Conven- formulating protocols, amendments, and annexes to tion, including — potentially — a financial mechan- the Convention and related protocols; and (v) the ism, technical advice and assistance programmes, a final clauses of the Convention. mechanism to monitor treaty compliance, and Evidence from other treaty-making processes provisions for ongoing consultation of the parties, shows that the institutions and procedural mechan- can help contribute to the adoption of effective isms established by the WHO Convention can global tobacco control measures. Overall, by provid- prompt timely consensus and action on cogent ing an ongoing and institutionalized platform for implementing protocols and, thus, contribute to the multilateral consultations on tobacco control, the implementation of the Convention and the advance- WHO Convention may be able to promote adoption ment of the global public good of international and implementation of effective tobacco control tobacco control (40). For example, environmental strategies worldwide. framework conventions and protocols are often WHO has the constitutional responsibility and designed to encourage state parties to adopt the unique opportunity to propel the development of implementing protocols by mandating regular and a Framework Convention on Tobacco Control. institutionalized meetings of the parties. In the case Importantly, the sheer process of negotiating and of some framework conventions, the mandatory seeking its adoption can also be considered a public provisions for consultation ‘‘offer the prospect of a good. WHO’s efforts to achieve global public virtually continuous legislative enterprise’’(45). Rapid support for an international regulatory framework implementation of the WHO Convention can also be for tobacco control may stimulate national policy encouraged by institutions and mechanisms that change and thus make a dramatic contribution to establish incentives for the parties, such as infor- curtailing the spiraling pandemic well before global mation, technology, training, technical advice and consensus on cogent tobacco norms is secured (40). assistance. Of course, the effective international law- making experiences achieved at times in the Conclusion environmental areas may not accurately reflect WHO’s potential to garner broad support for the Although numerous existing international legal mea- development and implementation of a Framework sures have direct or indirect implications for public Convention on Tobacco Control and related proto- health, international law-making is a largely uncharted cols. The extent to which international agreements area for the public health community. However, the are effective — and under what conditions — has development and negotiation of the WHO Conven- been a continuing source of theoretical fascination tion will require us to move into this area. Like many and dispute among scholars of international relations international environmental measures, the Conven- and international law. Although it is beyond the scope tion will be a binding agreement for states party to the of this article to detail the factors that may contribute agreement — based on scientific evidence — once the to the effective adoption and implementation of the tobacco control treaty enters into force. In fact, it can WHO Convention, it may be noted that tobacco well be argued that the scientific evidence base is much control does share the characteristic of ‘‘scientific firmer for an international legal agreement on tobacco certainty’’ which has galvanized effective interna- than, for example, in many areas of environmental law- tional action in some areas of environmental law (40). making where ‘‘scientific uncertainty’’ has been a Like the hole in the ozone layer above Antarctica dominant issue. which led to the conclusion of the Montreal Ozone Tobacco control is one of the most rational, Protocol, the health and economic consequences of evidence-based policies in health care. Moreover, the tobacco consumption are empirically established. In recent economic data released by the World Bank addition, the use of the framework convention strengthens immeasurably this bedrock of scientific protocol approach will allow countries to undertake evidence. On these grounds, the World Bank added substantive and/or institutional commitments recommends that ‘‘international organizations such as global consensus for concrete measures on as the United Nations agencies should review their tobacco control develops. existing programs and policies to ensure that tobacco control is given due prominence... and that they should Framework Convention on Tobacco address tobacco control issues that cross borders, including working with the WHO’s proposed Frame- Control: a global public ‘‘good’’ work Convention on Tobacco Control’’. As a rational, evidence-based approach, the WHO The technical disciplines involved in the Convention holds the potential of dramatically negotiation of the Convention will span several advancing global cooperation for tobacco control different sectors — including, inter alia, finance, and can thus be considered a potential intermediate foreign affairs, trade, and agriculture — and will public health good. The principles, norms and require a coordinated approach. In view of the

926 Bulletin of the World Health Organization, 2000, 78 (7) WHO Framework Convention on Tobacco Control tenacity and wealth of the industry sector of the provide, in the words of the industry itself, a rationale tobacco epidemic, the scientific evidence base for a global regulatory framework. It is now up to the supporting tobacco control efforts will need to be public health community to make a global legal linked with international politics since the negotiation framework an effective component of comprehen- of a legally binding agreement is very much in the sive tobacco control measures. As outlined in this realm of politics. As John McKinlay has recently article, the Framework Convention on Tobacco noted ‘‘the success of future public health activities Control is potentially an important global public — including preventive interventions — requires an good. The success or failure of this approach awareness of the magnitude and tactics of the provides a test case for the more active involvement macroeconomic lessons working against us’’ (46). of the public health community in international law- In this regard, recently disclosed industry documents making. n

Re´ sume´ La convention-cadre pour la lutte antitabac : un atout pour la sante´ publique Dans toutes les parties du monde, la sante´des au controˆ le des armes et a` l’interdiction des armes de populations est de plus en plus influence´e par des forces destruction de masse, a`lase´ curite´ nucle´aire et a`la e´conomiques, sociales, scientifiques, technologiques et radioprotection, a`lafe´condite´eta` la croissance culturelles transnationales. Les dimensions nationales et de´mographique. En outre, la recherche scientifique joue internationales des politiques de sante´e´tant de plus en un roˆ le croissant dans l’e´laboration des instruments plus e´troitement imbrique´es, une approche juridique juridiques internationaux lorsqu’il s’agit, par exemple, de internationale peut permettre de re´soudre certains s’attaquer aux proble` mes environnementaux trans- proble`mes. A titre d’exemple, le pre´sent article examine frontie`res. la convention-cadre re´cemment e´labore´e par l’OMS pour Si, au cours des dernie`res de´cennies, de nom- lutter efficacement contre les me´faits du tabac au plan breuses organisations et agences du syste`me des Nations mondial. Unies ont pris une part active au de´veloppement du droit Parce que le de´veloppement e´conomique a` grande international dans le domaine de la sante´ et dans e´chelle a de profondes re´percussions sur la sante´ d’autres secteurs connexes inte´ ressant la communaute´ publique, il importe d’e´laborer et de mettre en œuvre internationale, l’OMS est longtemps reste´e en marge de paralle`lement une re´glementation internationale rigou- ces efforts, n’usant que re´cemment du droit que lui reuse en matie`re de sante´. Bien que la protection et la confe`re sa Constitution de promouvoir l’e´laboration promotion de la sante´ publique rele`vent traditionnelle- d’une convention juridiquement contraignante dans un ment des compe´tences individuelles des nations, domaine quelconque de la sante´ publique mondiale. l’impact croissant de la mondialisation exige la mise en C’est en mai 1999 seulement que les Etats Membres de place de nouveaux cadres de collaboration inter- l’Organisation ont adopte´ une re´solutionenvue nationaux. La codification et l’e´laboration de normes d’acce´le´rer le processus de ne´ gociation et d’adoption juridiquement contraignantes deviennent donc de plus du premier traite´ promu par l’OMS – la convention-cadre en plus importantes a` mesure que l’interde´ pendance des pour la lutte antitabac. pays en matie`re de sante´ s’acce´le`re et qu’ils prennent Pourquoi le renforcement du droit international conscience de l’utilite´ de la coope´ ration pour re´soudre est-il aujourd’hui crucial pour la sante´ publique ? des proble` mes essentiels. Les conse´quences de la . Premie`rement, parce que la mondialisation des mondialisation sur la sante´, qu’elles soient positives ou proble`mes de sante´ publique rend indispensable ne´gatives, constituent un enjeu majeur, qui a de´ja` donne´ l’e´laboration de normes s’appliquant elles aussi a` lieu a` un renforcement des instruments juridiques toute la communaute´ des nations. internationaux. . Deuxie`mement, parce que l’expe´rience a fait la Ces derniers englobent aujourd’hui des questions preuve de l’efficacite´ d’accords internationaux fonde´s de plus en plus complexes, y compris certains proble`mes sur les connaissances scientifiques dans d’autres associe´s a` la procre´ation et au clonage humains, aux domaines e´ troitement lie´s a` la sante´ – notamment transplantations d’organes, aux maladies infectieuses l’environnement. e´mergentes, au commerce international des denre´es Enfin, parce que l’expe´rience des ne´gociations qui alimentaires, a`lase´ curite´ des services sanitaires et des ont abouti a` la convention-cadre de l’OMS pour la lutte produits pharmaceutiques, ou encore aux substances antitabac a confirme´ que les proble` mes de sante´ provoquant une de´pendance, comme les stupe´fiants. Du publique transnationaux peuvent eˆtre re´solus par une fait de la mondialisation, ils sont aussi intimement lie´sa` approche internationale, et que la recherche scientifique d’autres instruments du droit international touchant, dans les domaines de la sante´ publique et de l’e´conomie notamment, a` l’environnement et a` la lutte contre les fournit une base solide pour la formulation d’accords. polluants toxiques, a`lase´curite´eta` l’hygie`ne du travail,

Bulletin of the World Health Organization, 2000, 78 (7) 927 Special Theme – Tobacco

Resumen El Convenio Marco para la Lucha Antitaba´ quica: una baza mundial para la salud pu´ blica En la salud de las poblaciones influyen de forma creciente prohibicio´ n de las armas de destruccio´ n masiva, la en todo el mundo fuerzas transnacionales econo´ micas, seguridad nuclear y la proteccio´ n radiolo´ gica, y la sociales, cientı´ficas, tecnolo´ gicas y culturales. Las esferas fecundidad y el crecimiento demogra´ fico. Adema´s,enel nacionales e internacionales de las polı´ticas de salud desarrollo de instrumentos jurı´dicos internacionales, por esta´ n torna´ ndose cada vez ma´ s imbricadas e insepara- ejemplo para hacer frente a problemas ambientales bles. A modo de ejemplo de co´ mo pueden abordarse transfronterizos y mundiales, las pruebas cientı´ficas han esos problemas transnacionales mediante medidas sido un componente importante del procedimiento para jurı´dicas de a´ mbito internacional, en este artı´culo se la celebracio´ n de tratados. presenta un estudio pra´ ctico del Convenio Marco de la En contraste con la evolucio´ n registrada por la OMS para la Lucha Antitaba´ quica, iniciativa emprendida actividad normativa internacional en el campo de salud y recientemente para combatir la epidemia mundial de en otros sectores conexos de alcance internacional tabaquismo. durante los u´ ltimos decenios bajo los auspicios de gran Toda vez que el desarrollo econo´ mico en gran nu´ mero de organizaciones y organismos del sistema de escala tiene profundas repercusiones mundiales en la las Naciones Unidas, la OMS no ha utilizado nunca – salud pu´ blica, es necesario ampliar y aplicar paralela- hasta hace poco – su autoridad constitucional para mente la legislacio´ n sanitaria internacional. Aunque la promover el desarrollo de un convenio internacional de proteccio´ n y la promocio´ n de la salud pu´ blica han sido cara´ cter vinculante en ningu´ n sector de la salud pu´ blica tradicionalmente asuntos abordados a nivel nacional, la mundial. So´ lo en mayo de 1999 los Estados Miembros de influencia ra´ pida y generalizada de la mundializacio´n la OMS adoptaron una resolucio´ n que ha acelerado el exige nuevos marcos de colaboracio´ n internacional para proceso iniciado para negociar y adoptar el primer hacer frente a las amenazas mundiales que se ciernen tratado de la Organizacio´ n, a saber, el Convenio Marco sobre la salud y para crear oportunidades de promocio´n de la OMS para la Lucha Antitaba´ quica. de la salud. En consecuencia, la codificacio´n y la ¿Por que´ es tan importante en este momento para ejecucio´ n de normas sanitarias vinculantes resultan la salud pu´ blica el desarrollo del derecho internacional? crecientemente necesarias a medida que se acelera la El presente artı´culo se propone abordar esta pregunta en interdependencia internacional en materia de salud y tres partes. que los paı´ses reconocen la necesidad de cooperar para . Primero, se sostiene que la actual mundializacio´nde resolver problemas esenciales. Los efectos sanitarios de los problemas de salud pu´ blica configura un la globalizacio´ n, tanto positivos como negativos, se han panorama donde el desarrollo de normas y patrones convertido en un tema de polı´tica fundamental que mundiales resulta cada vez ma´ s necesario. conduce a la ampliacio´ n de la actividad legislativa . Segundo, la experiencia adquirida durante la internacional tradicional. elaboracio´ n de acuerdos internacionales en otros La legislacio´ n sanitaria internacional abarca hoy sectores estrechamente relacionados con la salud cuestiones cada vez ma´ s complejas, incluidos los internacional, en particular el del medio ambiente, aspectos de la reproduccio´ n humana y la clonacio´n demuestra que los acuerdos internacionales pueden humana, el trasplante de o´ rganos humanos, las influir en la realidad y que es posible usar pruebas enfermedades infecciosas emergentes, el comercio cientı´ficas en apoyo del desarrollo del derecho internacional de alimentos, el control de la seguridad internacional. de los servicios de salud y de los productos farmace´u- Por u´ ltimo, la experiencia de negociacio´ n del ticos, y la fiscalizacio´ n de sustancias adictivas tales como Convenio Marco de la OMS para la Lucha Antitaba´ quica los estupefacientes. Como resultado de la globalizacio´n, proporciona un estudio pra´ ctico que ilustra la manera de se admite tambie´n que la legislacio´ n sanitaria interna- abordar los problemas de salud pu´ blica transnacionales cional esta´ inextricablemente ligada a otros sectores mediante una perspectiva internacional, ası´ como la relacionados con el derecho ambiental internacional y el utilidad de los datos cientı´ficos sobre salud pu´ blica y control de los contaminantes to´ xicos, la legislacio´n economı´a como fundamento para el desarrollo de este laboral internacional y la salud y la seguridad acuerdo vinculante. ocupacionales, el control de los armamentos y la

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