Global Health Treaty Research Articles

Cigarette health warning label compliance in Nigeria: A multi-city observational study.

Tobacco remains the world's leading preventable cause of death, with the majority of tobacco-caused deaths occurring in low- and middle-income countries. The first global health treaty, the Framework Convention on Tobacco Control (FCTC), outlines a set of policy initiatives that have been demonstrated as effective in reducing tobacco use. Article 11 of the FCTC focuses on using the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information on the pack about the product.The objective of his study is to establish a surveillance system for tobacco packs in Nigeria to assess pack compliance with in-country health warning label requirements. The Tobacco Pack Surveillance System (TPackSS) monitors whether required health warnings on tobacco packages are being implemented as intended and identifies pack designs that might violate the communication of harm-related information and undermine the impact of the country's tobacco packaging laws. Tobacco cigarette packs were collected in three cities in 2019-2020. The intention was, to the extent possible, to construct a census of 'unique' pack presentations available for purchase in Nigeria. We implemented the TPackSS standardized Protocol for acquiring packs from 36 diverse neighborhoods across three cities. At the time of purchase, data on the price and place of acquisition of each pack were recorded. We photographed packs, coded, and archived them. Each pack was coded for compliance according to the current health warning label laws. Each pack was coded by two independent coders consistently. We routinely measured intercoder reliability and only retained variables for which a good level of reliability was achieved. Across the three cities in Nigeria, the team collected 90 tobacco packs. Overall, 77% of packs evaluated for HWL compliance complied with all the relevant common indicators of HWL compliance. There was a 92% compliance with the location of the HWL (e.g. top or bottom of pack, front or back panel) with in-country requirements. Of the four compliance indicators, the size of the HWL (the minimum required coverage) showed the lowest compliance (31%) (i.e. the HWL was too small on most of the packs). Label elements (such as color contrast or content of warnings) showed 85% compliance overall. The analysis of the packs showed various levels of compliance with Health Warning Label provisions for Nigeria. Periodic evaluations are required to ensure that minimum requirements are met.

A longitudinal analysis of MPOWER implementation, 2008-2018

Background In 2008, the World Health Organization (WHO) introduced MPOWER-a package of evidence-based, high-impact policy measures to help countries reduce tobacco use. These measures align with selected articles within the World Health Organization’s Framework Convention on Tobacco Control (FCTC), a global public health treaty to prevent and reduce tobacco use. Methods Observational longitudinal study involving 195 countries that submitted biannual national reports between 2008 and 2018. To report changes in MPOWER scores, countries were assessed using a validated checklist of the seven MPOWER indicators and a maximum possible unweighted composite score of 34 points. Covariate analysis was conducted among selected health, sociopolitical, and economic indicators. Results 176 out of 195 countries improved their MPOWER scores between 2008 and 2018, with two achieving full implementation (Brazil and Turkey). Twenty-three (23) countries representing 11.2% of the global population recorded an MPOWER scoring increase of at least 10 points between 2008 and 2018. The overall mean 10-year scoring increase was 5.1 points or a relative improvement of 27.1%. In 2018, 20 countries representing 10.4% of the global population excelled in MPOWER implementation by receiving a total composite score of at least 30 of 34 possible points. The MPOWER elements with the highest degree of implementation in 2018 include Warn (package), Protect (smoking ban) and Enforce (ad ban). Several covariates were positively associated with higher levels of MPOWER implementation, including cigarette affordability, the existence of national tobacco control objectives, the human development index score, the national corruption index score, national literacy rates and the political regime index score. Conclusions MPOWER implementation increased markedly between 2008 and 2018 in all seven WHO regions and countries representing all four World Bank income classifications. However, only two countries achieved full implementation by 2018. More work is needed to improve MPOWER implementation. Countries with low-income levels, compromised human development, reduced literacy rates, higher rates of corruption, and autocratic political regimes appear to struggle more with MPOWER implementation.

Development of Alcohol Control Policy in Vietnam: Transnational Corporate Interests at the Policy Table, Global Public Health Largely Absent.

This paper analyses input from global interests in the policy process leading up to the passing of alcohol control legislation in Vietnam in 2019. The global alcohol industry now relies on growth in volume in emerging markets in middle-income countries such as Vietnam, a large, rapidly industrialising country with a youthful population and emerging middle class. The industry's role in the alcohol policy process is compared with that of global health interests. Document analysis of letters and English language media coverage was supplemented by and triangulated with data from key informants on changes in the content of draft alcohol legislation and participant observation. The alcohol legislation was negotiated in the context of active engagement from the global alcohol industry and some input from global public health interests. The global alcohol industry established a partnership relationship with politicians using CSR and funded a local employee in Hanoi over the decade prior to the draft legislation being considered. Direct lobbying took place over the content of the legislation, which went through six published drafts. Trade and investment agreements provided a supportive environment and were referred to by both politicians and industry. In contrast public health resource was limited and lacked the support of a normative global policy to counter the economic imperatives. Vietnamese Ministry of Health proposals for cost effective alcohol policy were not enacted. Global commercial interests employed their considerable resources to engage in corporate social responsibility (CSR) and build partnerships with policy-makers over a long period, contributing significantly to an environment unsupportive of enacting effective alcohol control policy. The absence of structural support from a global health treaty on alcohol and lack of an equivalent level of long-term sustained input from global health actors contributed to the legislative outcome, which excluded proposed cost-effective policies to reduce alcohol harm.

India and the framework convention on tobacco control: the politics of rising power attitudes toward international rules

ABSTRACT This paper investigates why India actively negotiated and ratified the Framework Convention on Tobacco Control (FCTC), the first global health treaty to curb tobacco use worldwide. The World Health Organization’s (WHO) decision to conduct FCTC negotiations aligned with India’s shifting disease burden that was pivoting from infectious to non-communicable diseases, particularly cancer, which shot up due to surging tobacco use. The WHO’s decision to frame the agreement around constraining global tobacco commerce, particularly the might of multinational tobacco companies, meshed with the interests of New Delhi, which was concurrently seeking to curb surging tobacco consumption. This triggered a positive approach and attitude to FCTC negotiations, leading to India’s ratification. India’s negotiation and ratification of the FCTC shows that the literature(s) on rising powers and international organizations must consider how factors like the WHO’s institutional politics, specifically the intent to negotiate a focused global agreement to curb tobacco production and distribution worldwide, affects how countries perceive and seek to use that agreement to bolster domestic policy concerns like tobacco control.

Global Implementation of Tobacco Demand Reduction Measures Specified in Framework Convention on Tobacco Control.

IntroductionThe world’s first global health treaty, WHO Framework Convention on Tobacco Control (FCTC) aims to reduce tobacco product demand by focusing on tobacco taxes, smoking bans, health warning labels, and tobacco advertising bans. Previous studies almost unanimously suggest that FCTC has prompted countries to implement more effective tobacco demand reduction policies.Aims and MethodsBy taking into account the pre-FCTC status, country income level, and state capacity we studied if ratifying FCTC was associated with tobacco demand reduction measures in 2018/2019. We used logistic regression to assess the association of FCTC ratification with adoption demand reduction measures, accounting for years since ratification, baseline status, and other covariates.ResultsExcept for taxes, state of tobacco policy implementation before FCTC ratification did not predict adoption of FCTC policies. Time since FCTC ratification was associated with implementing smoking bans and pictorial HWLs. In contrast, while the tax rate prior to FCTC ratification was positively associated with increased taxes after FCTC ratification, time since FCTC ratification was marginally negatively associated with increases in tobacco taxes.ConclusionsWhile the FCTC was followed by implementation of compliant demand reduction policies, there are still many parties that have not implemented the FCTC, particularly increasing taxes and ending tobacco advertising and promotions.ImplicationsWe assessed changes in tobacco demand reductions measures over 22 years in 193 countries. By using internal tobacco industry documents, we were able establish a baseline before the FCTC negotiations. Unlike previous studies, we included four tobacco demand reductions measures: tobacco taxes, smoking bans, health warning labels, and tobacco advertising ban. The limitation of the study is that we do not have data to describe if demand reduction measures are actually enforced or what their effect on tobacco consumption is.

COVID-19 Vaccines as Global Common Goods: An Integrated Approach of Ethical, Economic Policy and Intellectual Property Management

Abstract The article deals with the current debate about COVID-19 Vaccines as global public/common goods. After a brief introduction on the global epidemiological and economic implication of the pandemic, the problem of the correct characterization of either vaccine or immunization/herd immunity as global public/common good, according to the necessary characteristics outlined by the pertinent economic theories, is addressed. The conclusion is that the term “global public good”/global common goods” has been extensively used in the last two years by policy makers, political leaders, academics, economists, international organizations, NGOs and others health groups, in a sort of “loose way”. Substantially, in order to underscore that equitable access to health products, including vaccines, health and biomedical technologies, medical services, medical devises, whose availability, accessibility, acceptability, affordability to the world is fundamental to tackling the pandemic. The current legal proprietary regime applied to vaccines, extensively covered by IPRs, has transformed an intrinsically non-excludable common/public good (the vaccines, due to their nature and characteristics) in something excludable and rival in consumption. Consequently, the article argues that what is needed is a swift in their legal governance. The current legal discipline of vaccines and health technologies must be changed to bring it into line with the non-excludable nature of these goods. The richest countries in the world, in pursuit of their “vaccine nationalisms”, have already collectively preordered 8.8 billion doses of vaccine, far in excess of need, thus obliging billions of people in the Global South to wait years to be vaccinated. In this respect, the article investigates the EU vaccines strategy and analyzes the Advanced Purchase Agreements signed by the European Commission with the major vaccine producers, enlightening the untenable secrecy and opacity with which the European Union’s executive has handled COVID-19 vaccine supply contracts, and how it has simply paid no more than lip-service to the concept of global common/public good by attributing a broad “private governance” to the pharmaceutical companies. Then, the various arguments, for and against, the Waiver Proposal to several sections of the WTO TRIPS agreement, introduced by India and South Africa on the TRIPS Council on October 2020, have been briefly summarized, accounting the current luck of needed consensus among the various members of the WTO. The article however describes an important number of new global and collaborative efforts already put in place by a myriad public and private actors to allow efficient development and production of vaccines in order to enhance a global access to vaccines. The article concludes by stressing the major developments in the U.S. patent’s landscape and in the Biden Administration’s attitude towards the current global health crisis, that leave hope for “extraordinary measures” to be agreed by the international community in near future. The auspice is that the time has finally arrived for the international community to develop reliable and long term solutions to tackle future global pandemic, preferably by the negotiation of a new WHO global health treaty, to secure universal fair access to essential technologies and vaccines and protecting them as global public/common goods.

Tütün Yasağının Genişletilmesinin Sigara Kullanma Olasılığı Üzerine Etkileri

Dünya genelinde hükümetler tütün ile ilişkili hast alıkları ortadan kaldırmak için tütün kullanımına karşı bir dizi önlemler alarak mücadele etmektedirler. Türkiye, Dünya Sağlık Örgütü’nün ilk global umumi sağlık antlaşmasını imzaladıktan sonra tütün salgın hastalığına karşı acilen bir dizi karşıt politikayı hayata geçirmiştir. Sigara tüketiminin azaltılması bağlamında yeni bir kanıt sunmak adına Türkiye için yapılan Küresel Yetişkin Tütün Anketleri 2008 ve 2012 verisetlerine Lineer Olasılık Modellerini uygulayarak tütün karşıtı politikanın etkilerini inceledik. 2009 ve 2010 yılları arasında uygulamaya konulan tütün karşıtı iki önemli politikanın sigara kullanıcısı olma olasılığı üzerinde istatistiksel olarak anlamlı ve negatif bir etkisi görülmektedir. Konuya cinsiyet perspektifinden yaklaştığımızda; bu politika her iki cinsiyetin de sigara kullanıcıları olma olasılıklarını düşürmektedir fakat bu etki yetişkin erkekler için daha fazladır. Eğitimin kadın ve erkek üzerindeki etkisi farklılaşmakta; eğitimli kadınların sigara içme olasılıkları daha yüksek iken yetişkin erkekler için bu durum tam tersidir. Politika yapıcılar tütün tüketimine önlem almak ve sigara salgınını durdurmak için bu çalışmanın sonuçlarını dikkatle incelemeli ve cinsiyet farklılıklarını dikkate alan bir takım politikalar geliştirmelidirler.

Corrigendum to "Network influences on policy implementation: Evidence from a global health treaty" [Soc. Sci. Med.] 222 (February 2019) 188-197.

Corrigendum to "Network influences on policy implementation: Evidence from a global health treaty" [Soc. Sci. Med.] 222 (February 2019) 188-197.

European Union Global Health Law

The European Union is an important player in global health issues. This paper firstly explains the concept of EU global health law and then examines a number of areas where the EU acts and may influence, directly or indirectly, global health issues (eg, trade, public health, health migration, development aid, and health security). What follows is an attempt to tie up the threads more systematically by advocating a Global Health Convention, based on human rights principles. Such a shared vision on global health law may help the EU and Member States to respond more effectively to global health challenges such as international trade, public health security and health threats. In line with EU Council Conclusions 2010, the focus is on four dominant areas of EU law, explained in more detail. The variety of measures and activities embodies: external trade and global health; EU health law and external relations; health migration and development initiatives; global health security: the emerging health/security nexus. Author conclude that examining the EU’s role in the global health debate, has revealed a ‘hodgepodge’ of legal issues, rather than a distinct body of rules reflecting a coherent framework of EU law. As a result, its role in the global health is largely influenced by other policy areas than health. What is missing is a common global health policy. Communication 2010 provided key elements of what reflects a fragmented, highly compartmentalised approach. Balancing international trade and other economic interests with global health issues requires a shared vision and strategy what is global health. Here, it is argued that the EU should take the lead in drafting such a common policy based on previous experiences in close collaboration with the key global health actor: the WHO. Formulating and implementing a global health treaty at Member State level, a Framework Convention on Global Health could respond to trade, in a more systematic and coherent manner, reflecting international health law principles and specifying State obligations.

Diferencias evitables en el cumplimiento de las medidas para el control del tabaco: Colombia, Costa Rica, Ecuador y Perú, 2017

El Convenio Marco para el Control del Tabaco que es considerado el primer tratado global de Salud Pública, expone la idea de que el mundo retroceda la epidemia del tabaquismo al implementar una serie de estrategias, entre las que se encuentra el paquete de medidas MPOWER. El objetivo de este artículo es revisar el avance del cumplimiento de estas medidas y las diferencias entre Colombia, Costa Rica, Ecuador y Perú, con una mirada crítica en la implementación de las medidas. Se realizó una búsqueda de literatura en Medline y Lilacs de la evolución de estas estrategias y los informes MPOWER publicados por la OMS hasta el 2017.Este análisis muestra el detalle de implementación de las estrategias por cada país y permite observar las diferencias en Colombia e identificar las brechas que es necesario cubrir con estrategias que impacten positivamente la carga de la enfermedad.

Network influences on policy implementation: Evidence from a global health treaty

This paper examines whether country implementation of a public health treaty is influenced by the implementation behaviors of other countries to which they have network ties. We examine implementation of the Framework Convention on Tobacco Control (FCTC) adopted by the World Health Organization in 2003 and ratified by approximately 94% of countries as of 2016. We constructed five networks: (1) geographic distance, (2) general trade, (3) tobacco trade, (4) GLOBALink referrals, and (5) GLOBALink co-subscriptions. Network exposure terms were constructed from these networks based on the implementation scores for six articles of the FCTC treaty. We estimate effects using a lagged Type 1 Tobit model. Results show that network effects were significant: (a) across all networks for article 6 (pricing and taxation), (b) distance, general trade, GL referrals, and GL co-subscriptions for article 8 (second hand smoke), (c) distance, general trade, and GL co-subscriptions for article 11 (packaging and labeling), and (d) distance and GL co-subscription for article 13 (promotion and advertising), (e) tobacco trade and GL co-subscriptions for article 14 (cessation). These results indicate that diffusion effects were more prevalent for pricing and taxation as well as restrictions on smoking in public places and packaging and labeling. These results suggest that network influences are possible in domains that are amenable to control by national governments but unlikely to occur in domains established by existing regulatory systems. Implications for future studies of policy implementation are discussed.

Progress in Tobacco Control in Singapore: Lessons and Challenges in the Implementation of the Framework Convention on Tobacco Control

AbstractSingapore has implemented tobacco control policies since the 1970s, more than three decades before it became party to the World Health Organization (WHO) Framework Convention on Tobacco Control—the first evidence‐based global health treaty in 2005. The country's stringent policies have resulted in a 13 per cent adult smoking prevalence rate, one of the lowest in the world. This article reviews how a mix of demand‐ and supply‐reduction measures with extensive regulation and stringent enforcement has contributed to Singapore's reputation as the ‘most hostile environment’ for tobacco companies. Its tobacco control policies can offer lessons for more effective tobacco control among its neighbouring countries.

Do cigarette health warning labels comply with requirements: A 14-country study

The Framework Convention on Tobacco Control, a global health treaty ratified by over 175 countries, calls on countries to ensure that tobacco packages carry health warning labels (HWLs) describing the harmful effects of tobacco use. We assessed the extent of compliance with 14 countries' HWL requirements. Unique cigarette packs were purchased in 2013 using a systematic protocol in 12 distinct neighborhoods within three of the ten most populous cities in the 14 low- and middle-income countries with the greatest number (count) of smokers. HWL compliance codebooks were developed for each country based on the details of country-specific HWL requirements, with up to four common compliance indicators assessed for each country (location, size, label elements, text size). Packs (n=1859) were double coded for compliance. Compliance was examined by country and pack characteristics, including parent company and brand family. Overall, 72% of coded cigarette packs were compliant with all relevant compliance indicators, ranging from 17% in the Philippines to 94% in Mexico. Compliance was highest for location of the warning (ranging from 75%–100%) and lowest for warning size (ranging from 46%–99%). Compliance was higher for packs bought in high SES neighborhoods, and varied by parent company and brand family. This multi-country study found at least one pack in every country – and many packs in some countries – that were not compliant with key requirements for health warning labels in the country of purchase. Non-compliance may be exacerbating health disparities. Tobacco companies should be held accountable for complying with country HWL requirements.

The Sustainable Development Goals: One-Health in the World's Development Agenda.

The Sustainable Development Goals (SDGs), adopted by the UN General Assembly in September 2015, embody a One-Health strategy — healthy people living on a habitable planet. Extending beyond the social development emphasis of the Millennium Development Goals (MDGs), which accelerated progress globally, though unequally, the SDGs also encompass a range of environmental and economic goals, with a health goal that is far more comprehensive than the infectious diseases and maternal/child health focus of the MDGs.To be achieved, the SDGs require resources and political commitment that is yet to be demonstrated. With a cost that could reach $5 trillion for the SDGs overall, achieving health targets will require a mix of increase domestic resources, including taxes on unhealthy foods and products, international assistance, and innovative financing. Annual reviews should identify and monitor threats to the SDGs, both internal contradictions and contradictory government policies such as discriminatory laws, and the necessary rights-based pathways forward. To improve accountability, health information systems with disaggregated data should be prioritized, along with independent monitoring and key governance indicators. Ambitious national benchmarks, drawing on WHO strategies and action plans, could provide markers of success for presently vague health targets.Three early indicators of progress on the health SDGs could be: 1) whether countries establish clear policies on universality, encompassing all people without discrimination, identifying and prioritizing populations with the least access; 2) whether universal health coverage fully incorporates population health; and 3) whether countries provide rapid and sustained increased funding for such necessities as adequate sanitation and nutritious food. A Framework Convention on Global Health, a global health treaty based in the right to health, could fill in critical gaps in the SDGs, creating accountability through capacity-building and compliance-enhancing mechanisms, establishing a financing framework, and ensuring right to health assessments and health in all policies. It could help establish a path forward based on equity and the right to health that would be truly transformative.

Imagining Global Health with Justice: In Defense of the Right to Health.

The singular message in Global Health Law is that we must strive to achieve global health with justice--improved population health, with a fairer distribution of benefits of good health. Global health entails ensuring the conditions of good health--public health, universal health coverage, and the social determinants of health--while justice requires closing today’s vast domestic and global health inequities. These conditions for good health should be incorporated into public policy, supplemented by specific actions to overcome barriers to equity. A new global health treaty grounded in the right to health and aimed at health equity--a Framework Convention on Global Health (FCGH)--stands out for its possibilities in helping to achieve global health with justice. This far-reaching legal instrument would establish minimum standards for universal health coverage and public health measures, with an accompanying national and international financing framework, require a constant focus on health equity, promote Health in All Policies and global governance for health, and advance the principles of good governance, including accountability. While achieving an FCGH is certainly ambitious, it is a struggle worth the efforts of us all. The treaty’s basis in the right to health, which has been agreed to by all governments, has powerful potential to form the foundation of global governance for health. From interpretations of UN treaty bodies to judgments of national courts, the right to health is now sufficiently articulated to serve this role, with the individual’s right to health best understood as a function of a social, political, and economic environment aimed at equity. However great the political challenge of securing state agreement to the FCGH, it is possible. States have joined other treaties with significant resource requirements and limitations on their sovereignty without significant reciprocal benefits from other states, while important state interests would benefit from the FCGH. And from integrating the FCGH into the existing human rights system to creative forms of compliance and enforcement and strengthened domestic legal and political accountability mechanisms, the treaty stands to improve right to health compliance. The potential for the FCGH to bring the right to health nearer universal reality calls for us to embark on the journey towards securing this global treaty.

The Tobacco Pack Surveillance System: A Protocol for Assessing Health Warning Compliance, Design Features, and Appeals of Tobacco Packs Sold in Low- and Middle-Income Countries.

BackgroundTobacco remains the world’s leading preventable cause of death, with the majority of tobacco-caused deaths occurring in low- and middle-income countries. The first global health treaty, the Framework Convention on Tobacco Control (FCTC), outlines a set of policy initiatives that have been demonstrated as effective in reducing tobacco use. Article 11 of the FCTC focuses on using the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information about the product on the pack.ObjectiveThe objective of this study was to establish a surveillance system for tobacco packs in the 14 low- and middle-income countries with the greatest number of smokers. The Tobacco Pack Surveillance System (TPackSS) monitors whether required health warnings on tobacco packages are being implemented as intended, and identifies pack designs and appeals that might violate or detract from the communication of harm-related information and undermine the impact of a country’s tobacco packaging laws. The protocol outlined is intended to be applicable or adaptable for surveillance efforts in other countries.MethodsTobacco packs were collected in 14 countries during 2013. The intention was, to the extent possible, to construct a census of “unique” pack presentations available for purchase in each country. The TPackSS team partnered with in-country field staff to implement a standardized protocol for acquiring packs from 36 diverse neighborhoods across three cities in each country. At the time of purchase, data on price and place of acquisition of each pack was recorded. The field staff, according to a standardized protocol, then photographed packs before they were shipped to the United States for coding and archiving.ResultsEach pack was coded for compliance with the country-specific health warning label laws, as well as for key design features of the pack and appeals of the branding elements. The coding protocols were developed based upon prior research, expert opinion, and communication theories. Each pack was coded by two independent coders, with consistency of personnel across the project. We routinely measured intercoder reliability, and only retained variables for which a good level of reliability was achieved. Variables where reliability was too low were not included in final analyses, and any inconsistencies in coding were resolved on a daily basis.ConclusionsAcross the 14 countries, the TPackSS team collected 3307 tobacco packs. We have established a publicly accessible, Internet archive of these packs that is intended for use by the tobacco control policy advocacy and research community.

The national and international regulatory environment in tobacco control.

Despite their lethality, cigarettes are subject to little regulation that directly restricts their contents or their legality. This may change in the near future with the Framework Convention on Tobacco Control (FCTC), the world's first global health treaty, now in force, as well as developments in a few individual countries. Cigarettes are subject to a substantial number of country-specific regulations regarding their conditions of sale: their price (mostly through taxation), the places where they can be consumed (clean indoor air laws), who can smoke them (prohibitions on their use by or sales to minors), how they can be advertised or promoted (if at all), and how they must be packaged (minimum pack sizes, warning labels, plain packaging). Such policies constitute the core of successful tobacco control. The FCTC has been ratified by 180 countries representing 90% of the world's population. The FCTC requires compliance with numerous provisions relating to the kinds of regulations noted above. The treaty also mandates explicit attention to direct product regulation. Several countries have such authority, at least in limited forms. In the US, for example, the Food and Drug Administration (FDA) now has the legal authority to regulate tobacco products, including their contents. The possibility exists that, in the foreseeable future, a country will mandate product standards that will substantially reduce the appeal of cigarettes and other combusted tobacco products, which are by far the leading sources of the death and disease associated with tobacco.

Did We Finally Slay the Evil Dragon of Cigarette Smoking in the Late 20th Century?: Unfortunately, the Answer Is No—the Dragon Is Still Alive and Well in the 21st Century and Living in the Third World. Shame on Us!

If cigarettes were introduced as a new consumer product today, it is unlikely they would receive government regulatory approval. Cigarettes have proven biologic toxicities (carcinogenesis, atherogenesis, teratogenesis) and well-established causal links to human disease. Things were very different in 1913 when the R. J. Reynolds Tobacco Company introduced the first modern cigarette, the iconic Camel. By the early 1950s, definitive scientific reports linked cigarettes and human disease, but it was more than a half century later (2006) that cigarette manufacturers were found guilty by a federal court of deceptive product marketing regarding the health hazards of tobacco use. In the United States, cigarette smoking remains a major but slowly declining problem. But in developing countries, cigarette use is expanding tremendously. In global terms, the epidemic of smoking-caused disease is projected to increase rapidly in coming decades, not decline. Society may have begun to slowly win the smoking battle in the developed world, but we are resoundingly losing the global war on smoking. All is not lost! There is some good news! The 2003 Framework Convention on Tobacco Control, supported strongly by the American College of Chest Physicians, is the first global public health treaty of the new millennium. Many developed societies have begun planning to rid their countries of cigarettes in what is called the Endgame Strategy, and now is the time for the international medical community to help change tobacco policy to a worldwide endgame approach to rid all humanity of smoking-related diseases.

Research to stop tobacco deaths.

In 2003, governments adopted the Framework Convention on Tobacco Control, the world’s first global health treaty. In the decade since the treaty was adopted by 178 member states of the World Health Organization, there have been substantial achievements in reducing tobacco use around the world. Research and evidence on the impact of interventions and policies have helped drive this policy progress. An increased and sustained focus on research is needed in the future to ensure that the gains of the global tobacco control movement are maintained, particularly in low- and middle-income countries, which are affected most strongly by the tobacco epidemic. In addition to current priorities, greater attention is needed to research related to trade agreements, prevention among girls, and the appropriate response to nicotine-based noncombustibles (including e-cigarettes).

Towards a framework convention on global health

Introduction What will it take to eliminate the gross health inequities that continue to plague the world, the unconscionable health gaps between the rich and poor? The eyes of the global health community are focused on the post-2015 sustainable development goals, with the World Health Organization [WHO] advocating for universal health coverage. Adding healthy life expectancy as an overarching goal would capture the broader determinants of health and offer a richer integration of multiple sectors. Beyond improving health, the United Nations [UN] should focus on equity, human rights, inclusive participation and accountability, (2) The stage is set for the post-2015 agenda to embrace global health with justice--improving healthy lives for everyone, with particular attention to marginalized communities. The sustainable development agenda, however, cannot achieve global health with justice without robust global governance. We urge adoption of a legally binding global health treaty--a framework convention on global health grounded in the right to health. What are the purposes and content of a framework convention and how can such a treaty help to achieve global health with justice? And what steps need to be taken to galvanize support for its adoption and implementation? This perspectives paper seeks to spark international dialogue on a framework convention on global health and to explore the pathways towards a global health treaty. Core purposes and content The Millennium Development Goals were instrumental in achieving considerable progress in global health, but they failed to close the health gap. The overriding purpose of a framework convention on global health would be to dramatically reduce the health disadvantages experienced by the marginalized and the poor, both within countries and between them, while reducing health injustices across the socioeconomic gradient. Guided by principles underlying the right to health and mutual responsibility, a framework convention would universally ensure three conditions that are essential for a healthy life: a well-functioning health system providing quality health care; a full range of public health services, such as nutritious food, clean water, and a healthy environment; and broader economic and social conditions conducive to good health, such as employment, housing, income support and gender equality. Substantial improvements in health would be achieved through a population-based strategy centred on the essential conditions for the public's health, ranging from food, water and clean air to hygienic conditions, injury prevention and liveable communities conducive to physical activity and to healthful eating habits. By embedding the conditions for good health within the environment and bringing these benefits to everyone, including the poorest and most remote communities, public health services would give everyone a fair chance for a healthy life. Universal access to all levels of health care [community services and primary, secondary and tertiary care] and to financial protection [to prevent impoverishment and catastrophic health expenditures] would afford everyone the services needed to prevent and treat injury and disease. Importantly, policies and actions across the full spectrum of government ministries are needed to ensure education, employment, housing, clean energy, transportation, gender equity and all other positive social determinants of health. A framework convention would establish a health financing framework with clear obligations, and would create an accountability regime with robust standards, monitoring and enforcement. It would advance health justice through engaging marginalized and underserved populations in making and evaluating policies and through comprehensive strategies and targeted interventions designed to overcome the barriers that prevent these populations from enjoying the conditions required for good health. …