Smoke and Mirrors

It's time for Washington to stop giving cigarette makers an open door to developing markets.

If it seems fewer people are smoking in the United States, that's because it's true. Since 1965, the proportion of U.S. adults who smoke has plummeted from 42 percent to 19 percent as a result of higher excise taxes, civil and criminal litigation, and tobacco-control programs in U.S. cities and states.

But as tobacco use declines in the United States, it is on the rise in low- and middle-income countries, spurred by higher incomes, trade liberalization, and intensive industry marketing. There are 1.2 billion smokers in the world, roughly one-third of the world's adult population. Seven-hundred million children -- approximately 40 percent of the world's youth population -- are exposed to second hand tobacco smoke at home. According to the World Health Organization (WHO), tobacco use already kills more people annually than HIV/AIDS, malaria, and tuberculosis combined. Unless urgent action is taken, it is expected to kill hundreds of millions more in the coming decades, mostly in developing countries. The World Economic Forum's 2010 global risk report ranked non-communicable diseases, for which tobacco use is a leading risk factor, as a greater threat to global economic development than fiscal crises, natural disasters, transnational crime and corruption, and infectious disease.

This week marks 10 years since President Bill Clinton signed an executive order, which remains in effect, requiring U.S. agencies to take "strong action to address the potential global epidemic of diseases caused by tobacco use." While the intervening decade has seen significant efforts to reduce smoking domestically, Washington continues to do too little to address the expanding tobacco use in developing countries and its devastating consequences.

At home, the U.S. government is cracking down on tobacco. In 2009, President Barack Obama signed a law that gave the U.S. Food and Drug Administration (FDA) sweeping new powers to regulate tobacco products. Graphic images of diseased lungs and deceased smokers will soon adorn cigarette packs sold in the United States. The Congressional Budget Office estimates that these new regulations will reduce U.S. youth smoking by another 11 percent over the next decade.

Abroad, however, U.S. engagement on tobacco control is minimal. The United States has yet to join the 171 countries that have ratified the WHO Framework Convention on Tobacco Control, a binding, comprehensive treaty designed to reduce tobacco supply and demand worldwide. Less than $7 million of the more than $8 billion global health budget in 2009 was dedicated to international tobacco control. Nearly every trade and investment agreement that the United States has negotiated over the last decade reduces tobacco tariffs and improves the protection of tobacco-related investments overseas. The same new law that restricts cigarette marketing and labeling in the United States specifically excludes cigarettes destined for sale or distribution abroad.

Multinational tobacco companies' strategy toward tobacco control has been the mirror image of the U.S. government's. In the United States, the industry's response to the new domestic tobacco-control initiatives has been relatively muted. The Altria Group, which owns Philip Morris USA, supported the 2009 anti-smoking legislation and has not protested the FDA's proposed graphic warnings. Again, the story is different abroad. Tobacco com­panies have aggressively sought to expand markets for their products in low- and middle-income countries and have fiercely opposed marketing and labeling regulations more modest than those currently proposed in the United States.

Multinational tobacco companies employ advertising tactics in lower-income countries --billboards, cartoon characters, and music sponsorships -- now prohibited in the United States. Young women, who have historically smoked less than men in most parts of the developing world, are a major target of these campaigns. And marketing gimmicks -- such as purse-packs containing super slim cigarettes -- have helped increase the rate at which girls smoke to the same rate as boys do in more than 60 percent of countries surveyed in the Global Youth Tobacco Survey conducted by the WHO, U.S. Centers of Disease Control and Prevention(CDC), and the Canadian Public Health Association.

In the world's poorest countries, where tobacco has not been consumed historically, multinational cigarette companies use investments in local tobacco production and corporate social responsibility programs to win new friends and future customers. These tactics have increased tobacco use throughout Asia, Eastern Europe, and Latin America. Many expect Africa will be next. Tobacco use is currently relatively low in Africa -- 20 percent for men and much less for women -- but there will be dire consequences if it increases: Many African governments lack the ability to implement effective national tobacco-control programs and the health-care resources to cope with a pandemic of tobacco-related diseases.

Multinational tobacco companies are exploiting U.S. and other affluent countries' trade policies to pursue these tactics and outmaneuver developing-country regulators. Increasingly, multinational tobacco companies use dispute resolution under trade and investment agreements to block labeling and advertising restrictions in low- and middle-income countries. Free trade agreements reduce tobacco product tariffs before developing countries can introduce adequate domestic tobacco control and taxation programs to compensate for the lower price of imported cigarettes.

Smoking-control efforts in developing countries are stalling in the face of fierce industry opposition. Tobacco industry promotional investments dwarf expenditures on tobacco control in these countries. In 2009, the WHO reported that less than 10 percent of the world's population is covered by any of the WHO-recommended measures to reduce demand for tobacco and regulate tobacco-industry marketing.

Some policymakers in Washington make the argument that American jobs depend on tobacco companies' free access to developing countries. But that's a false choice: Doing more for international tobacco control would not put U.S. jobs at risk. The United States currently exports significant volumes of high-quality tobacco leaf and premium cigarettes to Japan, Europe, and affluent Middle Eastern countries, but hardly anything at all to cost-sensitive developing-country markets. Moreover, cigarette production has largely shifted to overseas factories. With domestic consumption declining, the tobacco industry now provides less than 2 percent of the jobs in the six southeastern U.S. states most associated with tobacco growing and product manufacturing.

In fact, taking the lead on international tobacco control would clearly be in the national interest of the United States. In a recent speech before the United Nations, President Barack Obama cited global health and development as not only moral imperatives, but U.S. strategic and economic imperatives. U.S. investments in global health are visible, concrete, and highly valued; they save lives and enhance America's credibility around the world. Few global health threats can compare with the human and economic toll of tobacco-related diseases in developing countries. If disease prevention and global health are strategic U.S. priorities, then global tobacco control must be as well.

Fortunately, it's an especially opportune moment for U.S. leadership on international tobacco control. The scientific consensus that to­bacco use and secondhand smoke cause a plague of terminal and disabling diseases no longer faces serious challenge. The WHO Framework Convention on Tobacco Control is among the most widely subscribed treaties in the world and provides a blueprint for acting on the most evidence-based and cost-effective strategies for global tobacco control. A $500 million, multiyear commitment from the Bloomberg Initiative and the Bill and Melinda Gates Foundation has injected sorely needed resources into tobacco-control programs in 20 priority developing countries. Anti-smoking NGOs like the Campaign for Tobacco-Free Kids and the Framework Convention Alliance are doing groundbreaking work on global tobacco control and would be capable U.S. government partners. Increased U.S. engagement on global tobacco control can transform this momentum into sus­tainable progress.

A foundation for change exists within the U.S. government. Obama supports ratification of the WHO Framework Convention on Tobacco Control. The senior leadership at the State Department, the FDA, and the CDC include individuals with distinguished track records on tobacco control and prevention. Last year, the U.S. trade representative resisted congressional pressure to challenge other countries' tobacco-control regulations. Where the United States has engaged on international tobacco control, such as the CDC's efforts on global tobacco-use surveillance, it has made a significant difference.

The United States must not wait another 10 years to demonstrate internationally the same leadership it has shown on tobacco control domestically. Obama has said he supports the WHO framework convention; but he should not wait for the Senate to ratify it before integrating tobacco control into existing U.S. efforts on maternal and child health, disease control, and health-systems strengthening. The U.S. Treasury Department and FDA have extensive technical expertise that should be shared with develop­ing countries seeking to improve tobacco taxation, fight cigarette smuggling, and regulate tobacco products and their advertisement. The U.S. trade representative should stop seeking tobacco tariff reductions and cease including tobacco-related investments in trade and investment agreements with developing countries. This year's G-20 meeting in France and the upcoming U.N. High-Level Summit on Non-Communicable Diseases provide excellent opportunities for the United States to motivate other governments to likewise prioritize tobacco control.

Washington has already shown great courage and leadership in protecting its own citizens from the perils of tobacco. It's past time that the United States support the world's poorest countries in their efforts to do the same.


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