Author: Dr. Alfred Munzer, Director of Pulmonary Medicine Washington Adventist Hospital, Washington, DC; Former President, American Lung Association and Board Member, Action on Smoking and Health
I had a long and successful career as a pulmonologist treating many hundreds of patients with lung disease, but lending my voice to the negotiations of the FCTC and the hope it offers to end the global stranglehold the tobacco industry has on the health of millions of people, has definitely been a major highlight of my medical career.
From the Archives | Dr. Munzer’s Detailed Report on the FCTC, delivered to a national conference in early 2005.
I have been a physician and a lung specialist for over thirty years. And for over thirty years, eighty percent of the patients I have treated have had diseases due to smoking. There is nothing more frightening, nothing that causes more of a sense of helplessness than to be faced by a person who says, “I cannot breathe.” And that is why for thirty years I have been a volunteer for the American Lung Association. The American Lung Association is the nation’s oldest voluntary health agency. It was founded one hundred years ago on the premise that tuberculosis could be conquered not just through the care given to individual patients, but also through scientific research, through public health education, and, most importantly, through the enactment of sound public policy. Over the last century the targets of the American Lung Association and of the public health movement, have changed. But the premise that disease could be conquered through education, research and public policy has not.
Over the past forty years, since the first Surgeon General’s Report on Smoking and Health, through the activities of countless organizations, many of them represented in this room, there has been a revolution in the American public’s attitude toward smoking. Science taught us that nicotine is addictive and that tobacco causes death and disease. Public health education has brought about a broad public consensus that smoking is no longer the norm. And public policy has removed tobacco advertising from the airwaves, has curtailed youth access to tobacco products and has begun to protect the non-smoker from exposure to second-hand smoke. In the United States there has been an all too slow but steady decline in tobacco consumption. We have seen the benefits of increased taxes on tobacco products and of aggressive anti-smoking campaigns. California, Delaware, Connecticut, Maine and Massachusetts have passed strong smokefree workplace legislation. And we all can take some comfort in the millions of lives that have been saved as a result of our campaign.
But tobacco is an elusive enemy, an enemy more elusive than tuberculosis, polio, malaria or any infectious disease. The epidemic of tobacco-related death and disease is propagated not by any animal vector, but by human greed and corruption that are far more difficult to eradicate. It is fed by an industry that has violated every moral code known to man, an industry that like the Cosa Nostra continues to seduce, to lie, to maim, to kill. An industry that far more than the Cosa Nostra is shielded by friends in high places. And as a physician, therefore, day in and day out, I still see the pain and suffering exacted by smoking. And even in the United States, therefore, every day we still see thousands of children being led down the path of seduction, addiction, disease and death laid out by the tobacco industry.
On a global level the picture of the tobacco epidemic is even more grim. The consumption of cigarettes may be leveling off or even decreasing in some industrialized countries, but, because of an aggressive and ongoing marketing campaign by the tobacco industry, worldwide more and more people smoke and smokers are smoking more and more cigarettes. The tobacco companies produce five and a half trillion cancer sticks per year, one thousand for every man, woman and child on this planet. There are one and a quarter billion smokers in the world today. And half of them will die prematurely as a result of smoking. Tobacco already outpaces AIDS and tuberculosis among the global leading causes of death.
But the tobacco industry’s greatest crime against humanity forty years after the first Surgeon General’s Report lies in the export and in the shameless marketing, promotion and glamorization of its deadly product in developing countries. The developing world is beset by tragedy: poverty, war, famine, infectious disease, drought, floods and earthquakes. Why add the enslavement to tobacco and the plagues of cancer, heart disease, emphysema and stroke? And yet, by 2030 80% of the deaths caused by smoking will occur in the developing world.
The tobacco epidemic is a global epidemic. And a global epidemic demands a global answer. The much-maligned United Nations through the World Health Organization has taken the lead in placing tobacco control on the global public health agenda. Its Tobacco Free Initiative has developed a formidable worldwide database that allows us to measure the progression of the tobacco epidemic. And the Tobacco Free Initiative has also created public awareness programs that span the globe. But it is by championing and nurturing the Framework Convention on Tobacco Control that the World Health Organization has become the developing world’s best friend. The objective of the Framework Convention is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.”
While it may be the first convention developed under the auspices of the World Health Organization, there is ample precedent for the Framework Convention on Tobacco Control. The world community has long recognized that slavery and infectious diseases and air and water pollution and even alcohol and substance abuse do not respect national boundaries. And neither does tobacco. That is the basic premise of the Framework Convention. The World Health Organization could have chosen a different model in international law to address the tobacco issue. It could have promoted a treaty between tobacco producing and tobacco consuming countries. It could have added tobacco to the list of substances covered by the Convention on Narcotics and Dangerous Drugs. But it chose the model of a Framework Convention, because it recognized that the fight against tobacco wasn’t going to be won in a single battle, but that it would be a war fought over a long time, on many fronts and requiring new weapons and evolving strategies. Of all the tools available to international law, the Framework Convention is the most flexible and adaptive. But the danger of the framework convention can be that it is too general and too flimsy to support meaningful immediate action.
For those of us who attended some or all of the negotiations, it may have seemed like an eternity, but the Framework Convention on Tobacco Control was developed in record time. Its origins can be found in discussions that took place in 1995, but the World Health Assembly resolution calling for the development of the Framework Convention on Tobacco Control was passed in May 1999. Final action by the World Health Assembly took place less than four years later, just eight months ago when it voted unanimously to approve the convention and submit it for signature and ratification by the 191 member states of the United Nations. Since May when the convention was first open to signature, 78 countries have signed. So far Norway, Malta, Fiji, Sri Lanka and Seychelles have also ratified the convention. The convention goes into effect when 40 countries have signed and ratified it.
Much of the credit for the Framework Convention should go to the Davids of the developing world who stood up to the pressure from such Goliaths as the United States, Germany and Japan. Equally important was the role of non-governmental organizations gathered under the umbrella of the Framework Convention Alliance. Their constant buttonholing of delegates, their constant nagging, their willingness to shame countries when appropriate through three years of negotiations resulted in a Framework Convention on Tobacco Control that is far more specific than most framework conventions.
The key provisions of the Framework Convention are:
Comprehensive Ban on Advertising and Promotion (16) (17) (18)
Requirement that health warning labels occupy at least thirty and preferable fifty percent of the package (19) (20)
Prohibition against deceptive labels
Requirement that non-smokers be protected
Prohibition of the sale of tobacco products to minors
The regulation of the content of tobacco products
Unfortunately there are also some key omissions. There is no ban on duty free sales, no ban on vending machines, no specific ban on deceptive descriptors like “light” and “low tar.” And perhaps most regrettably, when we think of children in the developing world, there is no ban on the sale of single cigarettes. But this is where the flexibility of the framework convention model comes into play. The framework convention is not a final product. It is as its name says “a framework” to which future provisions in the form of protocols can be added. The FCTC provides for a “Conference of the Parties,” i.e. all those who have signed and ratified the convention to meet regularly to assess progress and to build on the framework convention.
With the exception of its provisions on smuggling, the FCTC is very different from other international agreements in that it does not regulate relations between states but imposes what states must do or should do within their borders to curb smoking. Through the powerful first words of its preamble, “The Parties to this Convention, determined to give priority to their right to protect public health…” the FCTC can affect international tobacco trade by shielding signatories from the General Agreements on Traffic and Trade. It has the potential of removing tobacco from all the adverse effects of globalization. The FCTC is a first step in the process of delegitamizing the trade of tobacco.
I have treated many patients with AIDS and I was proud of my government when it committed fifteen billion dollars to fight the scourge of AIDS in Africa. But I am ashamed of the role my government played in the negotiations for the Framework Convention on Tobacco Control. Clearly it was ready to sacrifice long-term improvement in global public health to serve the narrow interests of a rogue industry. For a while it seemed that the United States would be the lone holdout in the unanimous vote of the World Health Assembly to approve the convention.
The record of the United States in signing and ratifying international agreements is poor. Some of the motherhood-and-apple-pie treaties it has not signed or ratified are:
Convention on the Elimination of Discrimination Against Women
Convention on the Rights of the Child
Convention Against Transnational Organized Crime
Convention on Biologic Diversity
Convention on Land Mines
Convention Establishing an International Criminal Court
And yet, signing and ratifying the Framework Convention on Tobacco Control is in the best interest of the United States. The convention allows the United States to do for the tobacco epidemic what it failed to do in the fight against AIDS. For AIDS we are paying now for our failure to contain the epidemic through a sound program of prevention at its start. The Framework Convention on Tobacco Control allows us to keep the tobacco epidemic from areas as yet uninfected. For the United States the message is a simple one, “sign and ratify now or pay later.”
There are many domestic issues in tobacco control. And organizations involved in the domestic fight against tobacco can argue that they have enough on their plate without taking on the Framework Convention on Tobacco Control. But in all the domestic issues we face, none is more important than weakening the stranglehold of big tobacco. Joining the Framework Convention Alliance and working for the ratification of the Framework Convention here and abroad allows us to say no to big tobacco, no to five million deaths around the globe, no to an industry that, like the Cosa Nostra, hides behind a legal product to carry out its nefarious business and no to an industry that robs the American taxpayer of billions of dollars in tax revenue through its complicity in smuggling. And saying no means saying yes to more cities and states going smoke free. Saying no, and letting our elected leaders hear it, means saying yes to FDA control over tobacco products. Saying no, and letting the public hear it, means saying yes to eliminating smoking from movies. Saying no means saying yes to a smokefree society. Let us take a lesson from Ireland, Norway, New Zealand and Bhutan where making the Framework Convention part of public discourse has helped pass smokefree workplace legislation. The framework convention is no ordinary convention. It is a global public health movement.
About 100 years ago the world took a stand against the opium trade which was then a major source of revenue for the British Empire. The war against narcotics continues. But opium is no longer a measure of personal success or national wealth.
Likewise, the FCTC brings us one step closer to a day when smoking is no longer is a sign of personal success and when tobacco is no longer is a measure of national wealth or a legitimate commodity in international trade.
