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Translating the WHO Framework Convention on Tobacco Control (FCTC): Can we use tobacco control as a model for other non-communicable disease control?
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Translating the WHO Framework Convention on Tobacco Control (FCTC): Can we use tobacco control as a model for other non-communicable disease control? G. Lien, K. DeLand* DeLand Associates, LLC, 23 Anchorage Street, Marina del Rey, CA 90292, United States
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Tobacco use is the single most preventable cause of death in the world today. Unchecked,
Received 14 August 2011
tobacco-related deaths will increase to more than eight million per year by 2030. Galvanized
Received in revised form
by the seriousness of the threat, the Member States of the World Health Organization (WHO)
22 September 2011
negotiated the WHO Framework Convention on Tobacco Control (WHO FCTC), which
Accepted 23 September 2011
entered into force in 2005. The treaty has enjoyed tremendous global success, with more
Available online 29 October 2011
than 170 Parties, and is often called the most powerful tool in the fight against tobaccorelated morbidity and mortality. As the world undergoes the long-predicted transition
Keywords:
from communicable to noncommunicable diseases (NCDs) posing the greater health
Tobacco control
burden, seminal ideas, processes, and outcomes like the WHO FCTC can be used to inform
International law
decision-making and policy-making. To help begin such knowledge transfer, this paper first
Public health policy
examines how tobacco control evolved to become a reasonable, politically feasible topic for
Noncommunicable disease
treating in the highly globalized context of public health and NCDs. Next, some of the key achievements and challenges that have occurred over the past six years of WHO FCTC implementation are discussed. Finally, a consideration of how some of the successes and lessons learned in tobacco control appear in other NCD contexts is presented. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Tobacco use is the single most preventable cause of death in the world today. Though the numbers are often repeated, their impact is still shocking: tobacco kills more than five million people a year e more than tuberculosis, HIV/AIDS, and malaria combined.1 Unchecked, tobacco-related deaths will increase to more than eight million per year by 2030.2 Galvanized by these sobering statistics, the Member States of the World Health Organization (WHO) joined together and unanimously committed to stopping this epidemic by taking the unprecedented step of developing a treaty on tobacco control.3 Utilizing and, to a certain extent, inventing and reinventing the tools of
international law and global public health, they negotiated the WHO Framework Convention on Tobacco Control (WHO FCTC), which entered into force in 2005.4 The treaty has enjoyed tremendous global support, with more than 170 Parties, and is often called the most powerful tool in the fight against tobaccorelated morbidity and mortality.5 As the world undergoes the long-predicted transition from communicable to noncommunicable diseases (NCDs) posing the greater burden, seminal ideas, processes, and outcomes like the WHO FCTC can be used to inform decision-making and policy-making. To help begin such knowledge transfer, this paper first examines how tobacco control evolved to become a reasonable, politically feasible topic for treating in
* Corresponding author. Tel.: þ1 310 751 6809; fax: þ1 310 823 7013. E-mail address: [email protected] (K. DeLand). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.09.022
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the highly globalized context of public health and NCDs. Next, some of the key achievements and challenges that have occurred over the past six years of WHO FCTC implementation are discussed. Finally, a consideration of how some of the successes and lessons learned in tobacco control appear in other NCD contexts is presented.
Global public health, noncommunicable disease, and tobacco The effects of globalization, such as the increased used of air travel, and the now-common constant movement of people and goods, mean that diseases permeate national borders more quickly than ever before. The result is that states can no longer combat the transnational threat of disease singularly; they need to work together to target its cross-border nature. Increased international cooperation on disease control has also required a reconsideration of public health e what it is and how to address, improve, and move it forward in a globalized international community. One of the most notable and noticeable changes in the landscape has been the upsurge in new examples of health governance at all levels, subnational through global. With the recognition of the power of law as a public health tool, the collective notion of “global health governance” began to gain traction.6 This momentum has allowed for ever increasing international and multilateral cooperation on health issues, as states become more comfortable with negotiating on health matters and health governance itself becomes increasingly politically palatable. The codification and implementation of legally binding global public health norms is becoming increasingly important as international health interdependence accelerates and nations recognize the need for cooperation to solve essential problems.7 International legal experts have maintained that better use of international legal instruments could help achieve global public health goals.8 Alongside multilateral treaties, various hard- and soft-law international instruments already exist within public health, including international charters, codices, and codes of practice and guidance; legally binding regulations adopted by the World Health Assembly; nonbinding international codes; and regional legal agreements.9 In the ever-increasing move toward global health governance, international instruments will be increasingly important. Global health cooperation, negotiation, and attention have focused predominantly on communicable diseases, and in particular, on pandemic response. While these issues are clearly important, the paucity of global attention given to the world’s biggest killers e NCDs e is distressing. NCDs are currently estimated to kill around 36 million people per year, accounting for 63% of all deaths worldwide.10 And tobacco is one of the most serious culprits e one in six NCD deaths is caused by tobacco use.11 In this vein, the Lancet NCD Action Group and NCD Alliance have proposed five priority interventions to reduce global NCD death rates, chosen for their health effects, costeffectiveness, low cost of implementation, and political and financial feasibility. Of the five interventions, tobacco control is identified as the most urgent and immediate priority.11 Tobacco use is expensive, both on individual and population levels. Tobacco use has been shown to play into the
cycle of poverty, particularly among those who can least afford to spend a significant portion of their annual incomes on a product that does not benefit the household. The economic costs of tobacco use to governments are equally substantial. In addition to the high public health costs of treating tobaccocaused diseases, tobacco use kills or disables many people in their most productive years, thereby denying families their primary wage-earners; it consumes family income that should be spent in the home; and it raises the cost of health care.12 In a larger context, it deprives nations of a healthy workforce.13 Tobacco users are less productive at work because their poor health raises the incidence of sickness absence. Health impact alone, then, makes tobacco control a critical topic for multilateral negotiation. However, there are many serious health threats for which a treaty approach has not been considered. Treaties are high-profile, powerful tools, but they are laborious and expensive to produce and resource-intensive to administer and implement. The decision to pursue a legally binding instrument as a public health tool requires not only that the health concern be serious enough but also that the topic and context be amenable to an international legal solution. There have been a number of marked successes in the use of law to address public health concerns, and these successes provide insight into how and when law is most effective. Broad vaccination coverage, the use of seat belts, and the removal of lead from gasoline and paint are considered positive achievements in public health, and all are accomplished through legislation or regulation. In each case, a community affects individual behavior and choice though its governance structure. And in each case, something tangible and under human control is made either accessible or inaccessible. In countries that have implemented laws like the examples above, vaccines, seat belts, and lead-free gasoline and paint are available, while it is difficult to enroll children in school without vaccination records, to buy or sell a car without a seat belt, or to purchase lead-based paint or gasoline. The laws concerning vaccines, seat belts, and lead are all domestic public health laws. In considering whether or not to use an international legal approach, the domestic sphere is important e that sphere is, of course, where implementation of a treaty takes place e but it is also essential for a health topic to be transnational, both in impact and in possible solutions. That is, to be effectively addressed by a treaty, a health concern must be present in more than one country and must be something that countries can exert control over and monitor by mutual agreement. For example, malaria clearly fits the first criterion, but the second is harder: though things like mosquito nets can be made available, no amount of regulation is going to stop mosquitoes from breeding, biting people, or moving across borders.a a
It is worth noting that despite these difficulties, countries have turned to legal instruments e regulations rather than a treaty e to structure their cooperation and coordination with regard to the international spread of disease. Specifically, the revised International Health Regulations, which are binding on 194 countries, aims to help the international community prevent and respond to public health risks that have cross-border implications and that may be mitigated by regulation, such as yellow fever, cholera, and SARS, among others. Please see WHO International Health Regulations, 2005 (second edition). Geneva: World Health Organization, 2008.
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This paper presents only a fairly simple set of analyses, but these basic precepts for international public health law do provide a framework for considering why tobacco control was an appealing topic for WHO’s first treaty. First, tobacco use is a serious health threat, the vector of which can be controlled using legislation (e.g., raising taxes or eliminating smoking in public places) that in turn influences individual behavior. Additionally, the transnational nature of the tobacco industry, cross-border advertising, and advertising and sales of tobacco products on the internet, as well as the illicit trade of tobacco products, are genuine multilateral problems for which individual national responses do not provide feasible answers. Tobacco in particular highlights the limitations of nationallevel health governance in a globalizing world.14 Coordinated multilateral approaches are necessary to implement meaningful tobacco control. A number of health issues besides tobacco control could satisfy those criteria. This suggests that other, tobacco-control-specific qualities or considerations must also have been part of the milieu that allowed the WHO FCTC to be developed. These include a positive cost/benefit ratio, a strong evidence and advocacy base, and political palatability. Science-based evidence was crucial to maintaining political will in bringing the WHO FCTC to fruition, and such evidence lent political legitimacy to the process of its negotiation and adoption.15 The large body of scientific evidence on the health effects of tobacco consumption, coupled with evidence that the tobacco industry knew its products posed public health risks and failed to warn consumers, created the opportunity for the global health community e including governments and a strong cadre of advocates, non-governmental organizations, and researchers e to come together on the issue of tobacco control. From 1970 through the adoption of the WHO FCTC in 2003, the World Health Assembly unanimously adopted 20 resolutions pertaining to tobacco control.16 These resolutions, which created global consensus on the evidence base for and cost effectiveness of tobacco control, were essential to developing the ripe time for initiating negotiation of a treaty. A ‘ripe time’ denotes that that the time is right or ‘fertile’ enough to produce fruitful discussions. However, ripe time does not mean that all diplomacy conducted within this time frame will be successful, merely that less ripe periods are less likely to result in success and more ripe periods are more likely to result in success.17 It is crucial that a level of optimism and momentum be retained by the parties for the entire period. The 1998 Tobacco Master Settlement Agreement18 in the United States contributed to this momentum, giving the public health community a very public and very lucrative win against what had been an almost indomitable opponent, the tobacco industry. The identification of cost-effective interventions to control tobacco was also key to maintaining political will for the development of a treaty. Tobacco control is relatively inexpensive to implement and, in cases such as well-designed tobacco tax structures, has been shown to increase governmental revenue while concurrently reducing prevalence. Governments were increasingly aware that tobacco taxes can generate huge financial benefits which can be used to contribute to the funding of other tobacco control initiatives as well as other health goals.
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As with all politics and policy, the evolution of the WHO FCTC was driven by a combination of well-timed, synergistic circumstances and determined advocates; strong political will from countries; and a good foundation of evidence. It is possible that a similar convergence will propel another NCD topic into treaty negotiations, though six years’ worth of data on the WHO FCTC’s implementation presents a new layer of consideration for any other proposed negotiation.
Implementation of the WHO framework convention on tobacco control The WHO FCTC is without question the most powerful tool the international community has to reduce the global NCD burden. With over 170 Parties to the treaty, its provisions can affect the lives of more than 87% of the world’s population. The treaty demonstrates the role and strength of international law as a tool for achieving global public health goals. The frameworkprotocol approach utilized in this public health instrument sets out “baseline international norms” for tobacco control, as well as institutional arrangements for global governance of tobacco.15 The treaty itself includes provisions spanning economics, law, environment, and good governance and highlights the importance of the involvement of both state and nonstate actors from not only the health sector but also other policy sectors such as trade, education, and law enforcement.14 The treaty confers legally binding obligations on its Parties, which must be implemented through effective national laws. Its provisions encompass both demand- and supply-side strategies. It also incorporates the four key pillars in any comprehensive tobacco-control programme: (1) preventing initiation of tobacco use; (2) promoting cessation; (3) protecting the public from exposure to second-hand smoke; and (4) tobacco product regulation.19 Effective tobacco control, when properly implemented and backed by strong national legislation and enforcement, has the power to save millions of lives. Implementation of just four of the WHO FCTC’s population-based control measures could avert an estimated 5.5 million deaths over 10 years in 23 low- and middle-income countries that experience a high burden of NCD deaths.20 Accelerated implementation of the WHO FCTC can only mean more successes for global tobacco control. In this vein, we next examine some of the key successes and challenges of WHO FCTC implementation.
Successes In addition to reducing tobacco use prevalence rates and changing cultural attitudes, in particular toward smoking, there have been strong achievements in implementing some of the core provisions of the WHO FCTC. The most prominent of these include the placement of health warning labels on tobacco products, the implementation of smoke-free places, and tobacco product taxation.
Warning labels The Guiding Principles of the WHO FCTC state that every person should be informed of the health consequences, addictive nature, and mortal threat posed by tobacco
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consumption and exposure to tobacco smoke.21 Article 11, Packaging and labelling of tobacco products, requires Parties to implement effective measures to ensure that health warnings and messages are provided on tobacco products sold within their jurisdictions within three years after entry into force of the WHO FCTC.22 Such health warnings are required to conform to specified characteristics, e.g., they must be large, clear, visible, and legible; they must cover no less than 30% but preferably more than 50% of principal pack display areas; and they must be rotated. In 2008, the Conference of the Parties to the Convention adopted guidelines to assist Parties in implementing the provisions in Article 11.23 Health warnings and messages on tobacco product packages are effective in increasing public awareness of the dangers of tobacco consumption24 and therefore encourage both reduction and cessation of tobacco use.25,26 Warnings that include pictures are more effective than text-only warnings,27,28 particularly in countries with high illiteracy rates. The size of the warning is also important, as larger warnings are more noticeable.29 A cost-effective component of tobacco control,28,29 warning labels have been introduced all over the world, and today, more than 1 billion people live in countries that require large graphic health warnings to be shown on every cigarette package.30 Warning labels on packaging also reduce the marketing effect of tobacco product packaging, making it more difficult for tobacco companies to reinforce brand awareness.30 A move toward generic, plain packaging on tobacco products would further decrease the ability of the tobacco industry to promote its products.31 Plain-packaging legislation has been proposed in Australia and is being considered in the United Kingdom.
Smoke-free places Article 8 of the WHO FCTC, Protection from exposure to tobacco smoke, states that “Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability” and requires Parties to implement effective laws to provide “protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”.32 To assist Parties in meeting this obligation, the Conference of the Parties to the WHO FCTC adopted guidelines for the implementation of Article 8 that advocate for “the total elimination of smoking and tobacco smoke in a particular space or environment in order to create a 100% smoke-free environment” and maintain that there “is no safe level of exposure to tobacco smoke”.33 Non-smokers who breathe in second-hand tobacco smoke are recognized as being at risk. Exposure to second-hand tobacco smoke is estimated to have contributed to more than 600,000 deaths in 2004, about 1% of worldwide mortality.34 Ninety-eight countries have currently implemented some kind of policy requiring smoke-free environments; however, only 31 of these policies are fully comprehensive.30 Nevertheless, smoke-free policies at the subnational level are increasingly popular.12
Taxes Article 6 of the WHO FCTC, Price and tax measures to reduce the demand for tobacco, urges Parties to implement tax policies and
price policies on tobacco products and to prohibit or restrict sales to and importations by international travelers of tax- and duty-free tobacco products.35 Increasing tobacco product taxes and prices is extremely effective in reducing prevalence rates of tobacco use, particularly among the young and the poor, and can also generate significant increases in revenues.36 Increases in government revenues can contribute to increased funding of other tobacco control initiatives. More than 80% of all countries have taxation policies covering tobacco products30; tobacco excise taxes collect nearly US$ 167 billion globally each year.12 To assist governments in implementing effective tobacco taxation policies, WHO has published a technical manual on tobacco tax administration.36
Challenges As with any ambitious policy movement, implementation of the WHO FCTC has not been without challenges. Some challenges are inherent in the document itself; for example, the instrument is considered by some to cover too much or too little, to contain inadequate sanction measures, or to not appropriately address tobacco cultivation and crop substitution. However, as these provisions are intrinsic to the document, they are less amenable to resolution than are other challenges. Some of the external challenges are described below.
Negotiating protocols The WHO FCTC contemplates protocols in its text. Article 33, Protocols, provides the procedural route for adopting protocols to the Convention, and Article 13, Tobacco advertising, promotion and sponsorship, includes the forward-thinking provision that “Parties shall consider the elaboration of a protocol setting out appropriate measures that require international collaboration for a comprehensive ban on cross-border advertising, promotion and sponsorship”.37 At its first session, the Conference of the Parties to the WHO FCTC created two working groups to prepare templates for protocols on illicit trade in tobacco products and on cross-border advertising, promotion, and sponsorship of tobacco products.38 At its second session, the Conference of the Parties established an intergovernmental negotiation body for a protocol on illicit trade in tobacco products.39 The body was to submit a draft protocol to the Conference of the Parties at its fourth session. Progress has been slow and difficult. Despite concerted effort and substantial financial support from key Parties, the intergovernmental negotiating body was not able to finalize a draft protocol for consideration at the fourth session. The Conference of the Parties has extended the body’s mandate, and there is hope that a draft protocol will be submitted at the fifth session in 2012.
Enacting and enforcing advertising bans Article 13 of the WHO FCTC, Tobacco advertising, promotion and sponsorship, requires that each Party undertake a comprehensive ban of all tobacco advertising, promotion, and sponsorship, including cross-border advertising, promotion, and sponsorship originating from its territory, within five years after entry into force of the treaty for the Party. This provision has proven particularly difficult to implement. This is because
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although advertising campaigns can be a cost-efficient means of reaching large numbers of people, they can also be expensive.30 Furthermore, anti-tobacco advertising strategies are generally more effective when they are run over long periods. Advertising campaigns should run “for at least 6 months to affect awareness, 12e18 months to have an impact on attitudes, and 18e24 months to have an impact on behavior”.40 However, many tobacco control programmes are unlikely to have sufficient resources to run sustained campaigns.30 In addition, the tobacco industry often tries to prevent or limit anti-tobacco advertising campaigns, claiming that they are inaccurate and a misuse of government resources.30 At the moment, well over 100 countries should have implemented advertising bans, but only 19 have comprehensive bans on all forms of direct and indirect advertising.30
The tobacco industry The single largest challenge to WHO FCTC implementation is the tobacco industry, which continuously adapts its tactics to circumvent new laws and regulations controlling its activities. A recent study undertaken by WHO’s Tobacco Free Initiative of legal cases and negotiations related to tobacco product disclosures found that seven factors were repeatedly argued by the industry when opposing disclosure legislation: (1) lack of jurisdiction; (2) domestic property rights; (3) technical barriers to trade; (4) international intellectual property rights; (5) privacy rights; (6) burden; and (7) vagueness.41 In addition to invoking legal arguments to oppose regulation, the industry has been innovative in making tobacco products more appealing, using additives and flavorings to enhance their taste. More worrisome is the invention of electronic nicotine delivery systems (electronic cigarettes, or “e-cigs”), which deliver nicotine to the respiratory system without producing smoke. WHO has stated its concern over the safety and efficacy of this class of products, as well as the lack of any published studies of their health effects.42 There is every reason to believe that the industry will continue to press any advantage, create loopholes wherever it can, and continue to fight for its existence. In this effort, it will spend billions of dollars.
Building on the successes of and lessons learned from the WHO FCTC The WHO FCTC has raised awareness of the benefits of using legal instruments to achieve public health goals. Indeed, the achievements of the WHO FCTC have led to calls to translate its successes to other public health problems, in particular, other NCD risk factors, such as the harmful use of alcohol and diet and nutrition. Parallels are often drawn between tobacco control and alcohol control. There have even been numerous calls for a framework convention on alcohol control.43e47 However, many of the critical early factors that drove the negotiation of the WHO FCTC e including strong political will and a long history of multilateral resolutions e are not in place for alcohol. Additionally, some have noted that alcohol use “is more widely and deeply embedded in many parts of the world than tobacco use” and has been used much longer “than the 100 years or so that tobacco use has been embedded in high-
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income countries”.43 This may present a higher threshold for taking international political action to create legally binding provisions on alcohol control. There has been some movement to create “soft” international agreement on alcohol, though. In 2010 the 63rd World Health Assembly unanimously endorsed the Global strategy to reduce the harmful use of alcohol, which contains “a portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level”.48 Among the policy options offered in the global strategy are a number that reflect the tobacco control model generally and the WHO FCTC specifically, including availability of alcohol (regulating alcohol sales and implementing age restrictions); marketing of alcoholic beverages (limiting or banning advertising, promotion and sponsorship); pricing policies (strategic taxation to reduce consumption); reducing the negative consequences of drinking and alcohol intoxication (providing health warning labels); reducing the public health impact of illicit alcohol and informally produced alcohol (regulating production, tracking and tracing products, enforcement and international cooperation); and monitoring and surveillance.49 Perhaps the global strategy, in combination with the strong public health advocacy movement in this area and the scientific evidence detailing alcohol’s damaging health effects that continues to accrue, will be the first steps in creating a foundation for moving toward negotiation on binding alcohol control measures. Public health advocates are also actively exploring whether and how policy interventions tested in tobacco control can apply to the food industry, particularly in monitoring and controlling industry practice.50 Further, tax and pricing strategies that clearly reflect the tobacco control experience are being proposed for sugar-sweetened beverages and snack foods to help begin to control the obesity epidemic.51 As with alcohol control, there are challenges inherent to controlling food and diet that create a more complicated, nuanced discourse than is the case for tobacco control. Specifically and in direct contrast with tobacco, while the wrong foods can be harmful, the right foods and appropriate nutrition are essential to life and must be available to all people. The recent high-level meeting of the United Nations General Assembly on NonCommunicable Diseases on 19-20 September 2011 provided an excellent opportunity to highlight on a global stage the need for further and fuller implementation of the WHO FCTC. Given this, there are concerns in many sectors, including food manufacturers, policymakers, and members of the public, that applying the lessons of tobacco control to other areas will result in expensive, heavy-handed legal restrictions that may adversely affect food availability.52 Anti-regulation is a consistent theme across the spectrum of NCD control work, and though it did not prevent success in tobacco control, food access has some more complicated aspects, so these arguments may frustrate efforts to move international diet and nutrition control toward legal negotiations. Despite the challenges, though, the World Health Assembly has also made strides forward in this area, endorsing the WHO Global Strategy on Diet, Physical Activity and Health in 2004.53 Here, too, the strategies often mirror those in the WHO FCTC, including promoting education, communication and public awareness; controlling marketing, advertising, sponsorship
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and promotion; providing informative labeling and health information; discouraging misleading descriptors and claims on food products; price, tax and subsidy measures; and monitoring and surveillance.53 While the very formal, highly negotiated treaty or framework convention/protocol approach of the WHO FCTC may not suit either alcohol or diet at this point, promising non-treaty instruments addressing NCDs now exist in global strategies and the foundations may be laid for developing global standards and regulations to implement them. For example, global standards or regulations on alcohol and food product packaging and labeling, as well as the advertising of these products, particularly in relation to marketing them to children, could help ease the NCD burden. Each step toward global standards and regulations will further pave the way for the possibility of generating international law in these areas. As evidenced by the tobacco experience, controlling alcohol and unhealthy food and drink through international legal instruments will require that the body of supporting scientific evidence, strong commitment from states, and dedicated support from a global network of non-governmental organizations continue to be fostered. Vigorous negotiations are required to ensure that a carefully balanced instrument is achieved that takes into account scientific, economic, social, and political considerations of what is to be controlled.43 Further, commitment e both political and financial e would be necessary not only in the negotiating stages but also in implementation.
Conclusion The WHO FCTC emerged from a sea of scientific evidence and political will to fight the tobacco epidemic and industry. Although the negotiation process was highly political and at times difficult, the clear evidence of the potential health effects and availability of cost-effective interventions, along with continued strong support from governments and civil society, made the inception of the treaty possible. The success of the treaty and the tangible benefits that have already been secured will positively influence the health of millions of people today and in the future. Benefitting from the tobacco control and WHO FCTC experience and translating those successes to other areas of public health e in particular, to other NCDs e will require concerted effort and may require some creativity; not every topic may be ripe for developing a treaty, but the foundations that may allow for future international negotiation, agreement, and movement forward with other types of international instruments are being laid. In The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, adopted by the UN General Assembly on 18 September 2011, governments recognized the seriousness of NCDs, acknowledged the WHO FCTC and similar instruments, and committed to concerted international cooperation to address NCDs.54 Though there was no call to develop other mutually binding instruments, the high-profile meeting and the presence of many heads of state perhaps demonstrates a new, increased political will to address the enormous health, social and economic burdens attributable to NCDs. There remain substantial challenges e political, economic and technical e but
using the law in innovative ways to bring about great improvements in global NCD control holds genuine promise that should continue to be explored, supported and furthered.
references
1. WHO. 10 facts on secondhand smoke. http://www.who.int/ features/factfiles/tobacco/en/index.html (accessed on 20. 07.11). 2. WHO. Tobacco fact sheet no.339, http://www.who.int/ mediacentre/factsheets/fs339/en; 2011 (accessed on 20.07.11). 3. WHO. World Health Assembly Resolution 49.17, International framework convention for tobacco control; 1996. 4. WHO. WHO Framework Convention on Tobacco Control (updated 2004, 2005). Geneva: World Health Organization, http://www. who.int/tobacco/framework/WHO_FCTC_english.pdf; 2003 (accessed on 20.07.11). 5. WHO. WHO World No Tobacco Day. Three ways to save lives. Geneva: World Health Organization; 2011. 6. Lee K, Goodman H. Global policy networks: the propagation of health care financing reform since the 1980s. In: Lee K, Buse K, Fustukian S, editors. Health policy in a globalizing world. Cambridge: Cambridge University Press; 2002. 7. Taylor A, Bettcher D. WHO Framework Convention on Tobacco Control: a global "good" for public health. Bull World Health Organ 2000;78:920e9. 8. Shattuck H, Roemer R, Connor S, Curran W. American Bar Association report (recommendations and reports): World Health Organization. Int Lawyer 1996;30:686e95. 9. Yach D, Bettcher D. The globalization of public health. II: The convergence of self-interest and altruism. Am J Public Health 1998;88:738e41. 10. Alwan A, MacLean D, Riley L, d’Espaignet E, Mathers D, Stevens G, et al. Monitoring and surveillance of chronic noncommunicable diseases: progress and capacity in highburden countries. Lancet 2010;376:1861e8. 11. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377:1438e47. 12. WHO. WHO report on the global tobacco epidemic implementing smoke-free environments. Geneva: World Health Organization; 2009. 13. WHO Western Pacific Region. Health topics: tobacco. http:// www.wpro.who.int/health_topics/tobacco/overview.htm (accessed on 20.07.11). 14. Collin J, Lee K, Bissell K. The framework convention on tobacco control: the politics of global health governance. Third World Q 2002;23:265e82. 15. Magnusson R. Non-communicable diseases and global health governance: enhancing global processes to improve health development. Globalization and Health 2007;3:1e16. 16. WHO. WHA Resolutions 23.32 (1970); 24.48(1971); 29.55 (1976); 31.56 (1978); 33.35 (1980); 39.14 (1986); 40.38 (1987); 41.25 (1988); 42.19 (1989); 43.16 (1990); 44.26 (1991); 45.20 (1992); 46.8 (1993); 48.11 (1995); 49.16 (1996); 49.17 (1996); 52.18 (1999); 53. 16 (2000); 54.18 (2001); and 56.1 (2003). http://www.who.int/ fctc/about/wha_resolutions/en/index.html (accessed on 20. 07.11). 17. Greig M. Moments of opportunity: recognizing conditions of ripeness for international mediation between enduring rivals. J Conflict Resolution 2001;45(6):691e718. 18. National Association of Attorneys General. Master Settlement Agreement, http://www.naag.org/backpages/naag/tobacco/ msa/msa-pdf; November 1998 (accessed on 20.07.11). 19. WHO. WHO Technical Report Series 945. The scientific basis of tobacco product regulation. Geneva: World Health Organization,
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 8 4 7 e8 5 3
20.
21.
22.
23.
24.
25. 26.
27.
28.
29.
30.
31. 32.
33.
34.
35.
36. 37.
http://www.who.int/tobacco/global_interaction/tobreg/ 9789241209458.pdf; 2007 (accessed on 20.07.11). Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;70:2044e53. WHO. WHO Framework Convention on Tobacco Control (Article 4) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20.07.11). WHO. WHO Framework Convention on Tobacco Control (Article 11) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20 July 2011). WHO. Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and labeling of tobacco products). Geneva: World Health Organization, http://www.who.int/fctc/guidelines/article_11.pdf; 2008 (accessed on 20.07.11). Hammond D, Fong G, McNeill A, Borland R, Cummings K. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006;15(suppl. 3):iii19e25. Borland R. Tobacco health warnings and smoking-related cognitions and behaviours. Addiction 1997;92:1427e35. Fathelrahman A, Omar M, Awang R, Borland R, Fong GT, Hammond D, et al. Smokers’ responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine Tob Res 2009;11:248e53. Thrasher J, Hammond D, Fong G, Arillo-Santilla´n E. Smokers’ reactions to cigarette package warnings with graphic imagery and with only text: a comparison between Mexico and Canada. Salud Pu´blica de Me´xico 2007;49(suppl. 2):S233e40. Hammond D, Fong G, Borland R, Cummings K, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med 2007;32:202e9. Borland R, Wilson N, Fong G, Hammond D, Cummings K, Yong H, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control 2009;18:358e64. WHO. WHO report on the global tobacco epidemic warning about the dangers of tobacco. Geneva: World Health Organization; 2011. Freeman B, Chapman S, Rimmer M. The case for the plain packaging of tobacco products. Addiction 2008;103:580e90. WHO. WHO framework convention on tobacco control (Article 8) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed 20.07.11). WHO. Guidelines for implementation of Article 8 of the WHO Framework Convention on Tobacco Control (Protection from exposure to tobacco smoke). Geneva: World Health Organization, http://www.who.int/fctc/cop/art%208% 20guidelines_english.pdf; 2008 (accessed 20.07.11). ¨ berg M, Jaakkola M, Woodward A, Peruga A, Pru¨ss-Ustu¨n A. O Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet 2011;377:139e46. WHO. WHO Framework Convention on Tobacco Control (Article 6) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20.07.11). WHO. WHO technical manual on tobacco tax administration. Geneva: World Health Organization; 2010. WHO. WHO Framework Convention on Tobacco Control (Article 33, Article 13) (updated 2004, 2005). Geneva: World Health
38.
39.
40.
41.
42.
43. 44.
45.
46.
47. 48.
49.
50.
51.
52.
53.
54.
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Organization, http://www.who.int/tobacco/framework/ WHO_FCTC_english.pdf; 2003 (accessed on 20.07.11). WHO. Decisions and ancillary documents (decision FCTC/ COP1(16) Elaboration of protocols). Geneva: World Health Organization. http://apps.who.int/gb/fctc/PDF/cop1/cop1_ 06_cd_decisionsdocumentsauxiliaires-en.pdf (accessed on 20.07.11). WHO. Decisions and ancillary documents (decision FCTC/ COP2(12) Elaboration of a protocol on illicit trade in tobacco products). Geneva: World Health Organization. http://apps. who.int/gb/fctc/PDF/cop2/COP2_07_CDDecisions-en.pdf (accessed on 20.07.11). Schar E, Gutierrez K, Murphy-Hoefer R, Nelson D. Tobacco use prevention media campaigns: lessons learned from youth in nine countries. Atlanta, GA: US Department of Health and Human Services; 2006. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. WHO. Work in progress in relation to Articles 9 and 10 of the WHO Framework Convention on Tobacco Control. Report by WHO’s Tobacco Free Initiative. Document FCTC/COP/4/INF.DOC./2. Geneva: World Health Organization, http://apps.who.int/gb/ fctc/PDF/cop4/FCTC_COP4_ID2-en.pdf; 2010 (accessed on 20. 07.11). WHO. WHO Study Group on Tobacco Product Regulation. Report on the scientific basis of tobacco product regulation: third report of a WHO study group. Geneva: World Health Organization; 2010. Casswell S, Thamarangsi T. Reducing the harm from alcohol: call to action. Lancet 2009;373:2247e57. World Medical Association. World Medical Association statement on reducing the global impact of alcohol on health and society. Chile: WMA General Assembly, http://www.wma.net/en/ 30publications/10policies/a22; 2005 (accessed on 20.07.11). American Public Health Association. A call for a framework convention on alcohol control, http://www.apha.org/advocacy/ policy/policysearch/default.htm?id¼1339; 2006 (accessed on 20.07.11). Jernigan D, Monteiro M, Room R, Saxena S. Towards a global alcohol policy: alcohol, public health and the role of WHO. Bull World Health Organ 2000;78:491e9. Lancet The. A framework convention on alcohol control. Lancet 2007;370:1102. WHO. WHA Resolution 63.13 Global strategy to reduce the harmful use of alcohol. Geneva: World Health Assembly, http://apps. who.int/gb/ebwha/pdf_files/WHA63-REC1/WHA63_REC1-P2en.pdf; 2010 (accessed on 18.09.11). WHO. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization, http://www.who.int/ substance_abuse/alcstratenglishfinal.pdf; 2010 (accessed on 18.09.11). Brownell K, Warner K. The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? Milbank Q 2009;87:259e94. Chaloupka F, Davidson P. Applying tobacco control lessons to obesity: taxes and other pricing strategies to reduce consumption. Tob Control Leg Consortium; 2010. Mercer S, Green L, Rosenthal A, Husten C, Khan L, Dietz W. Possible lessons from the tobacco control experience for obesity control. Am J Clin Nutr 2003;77:1073Se82. WHO. WHA Resolution 57.17 Global strategy on diet, physical activity and health. Geneva: World Health Assembly, http:// apps.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf; 2004 (accessed on 18.09.11). UN. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. A/66/L.1. New York: UN General Assembly, http:// www.un.org/ga/search/view_doc.asp?symbol¼A/66/L. 1&Lang¼E; 2011 (accessed on 20.09.11).
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Translating the WHO Framework Convention on Tobacco Control (FCTC): Can we use tobacco control as a model for other non-communicable disease control? G. Lien, K. DeLand* DeLand Associates, LLC, 23 Anchorage Street, Marina del Rey, CA 90292, United States
article info
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Article history:
Tobacco use is the single most preventable cause of death in the world today. Unchecked,
Received 14 August 2011
tobacco-related deaths will increase to more than eight million per year by 2030. Galvanized
Received in revised form
by the seriousness of the threat, the Member States of the World Health Organization (WHO)
22 September 2011
negotiated the WHO Framework Convention on Tobacco Control (WHO FCTC), which
Accepted 23 September 2011
entered into force in 2005. The treaty has enjoyed tremendous global success, with more
Available online 29 October 2011
than 170 Parties, and is often called the most powerful tool in the fight against tobaccorelated morbidity and mortality. As the world undergoes the long-predicted transition
Keywords:
from communicable to noncommunicable diseases (NCDs) posing the greater health
Tobacco control
burden, seminal ideas, processes, and outcomes like the WHO FCTC can be used to inform
International law
decision-making and policy-making. To help begin such knowledge transfer, this paper first
Public health policy
examines how tobacco control evolved to become a reasonable, politically feasible topic for
Noncommunicable disease
treating in the highly globalized context of public health and NCDs. Next, some of the key achievements and challenges that have occurred over the past six years of WHO FCTC implementation are discussed. Finally, a consideration of how some of the successes and lessons learned in tobacco control appear in other NCD contexts is presented. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Tobacco use is the single most preventable cause of death in the world today. Though the numbers are often repeated, their impact is still shocking: tobacco kills more than five million people a year e more than tuberculosis, HIV/AIDS, and malaria combined.1 Unchecked, tobacco-related deaths will increase to more than eight million per year by 2030.2 Galvanized by these sobering statistics, the Member States of the World Health Organization (WHO) joined together and unanimously committed to stopping this epidemic by taking the unprecedented step of developing a treaty on tobacco control.3 Utilizing and, to a certain extent, inventing and reinventing the tools of
international law and global public health, they negotiated the WHO Framework Convention on Tobacco Control (WHO FCTC), which entered into force in 2005.4 The treaty has enjoyed tremendous global support, with more than 170 Parties, and is often called the most powerful tool in the fight against tobaccorelated morbidity and mortality.5 As the world undergoes the long-predicted transition from communicable to noncommunicable diseases (NCDs) posing the greater burden, seminal ideas, processes, and outcomes like the WHO FCTC can be used to inform decision-making and policy-making. To help begin such knowledge transfer, this paper first examines how tobacco control evolved to become a reasonable, politically feasible topic for treating in
* Corresponding author. Tel.: þ1 310 751 6809; fax: þ1 310 823 7013. E-mail address: [email protected] (K. DeLand). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.09.022
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the highly globalized context of public health and NCDs. Next, some of the key achievements and challenges that have occurred over the past six years of WHO FCTC implementation are discussed. Finally, a consideration of how some of the successes and lessons learned in tobacco control appear in other NCD contexts is presented.
Global public health, noncommunicable disease, and tobacco The effects of globalization, such as the increased used of air travel, and the now-common constant movement of people and goods, mean that diseases permeate national borders more quickly than ever before. The result is that states can no longer combat the transnational threat of disease singularly; they need to work together to target its cross-border nature. Increased international cooperation on disease control has also required a reconsideration of public health e what it is and how to address, improve, and move it forward in a globalized international community. One of the most notable and noticeable changes in the landscape has been the upsurge in new examples of health governance at all levels, subnational through global. With the recognition of the power of law as a public health tool, the collective notion of “global health governance” began to gain traction.6 This momentum has allowed for ever increasing international and multilateral cooperation on health issues, as states become more comfortable with negotiating on health matters and health governance itself becomes increasingly politically palatable. The codification and implementation of legally binding global public health norms is becoming increasingly important as international health interdependence accelerates and nations recognize the need for cooperation to solve essential problems.7 International legal experts have maintained that better use of international legal instruments could help achieve global public health goals.8 Alongside multilateral treaties, various hard- and soft-law international instruments already exist within public health, including international charters, codices, and codes of practice and guidance; legally binding regulations adopted by the World Health Assembly; nonbinding international codes; and regional legal agreements.9 In the ever-increasing move toward global health governance, international instruments will be increasingly important. Global health cooperation, negotiation, and attention have focused predominantly on communicable diseases, and in particular, on pandemic response. While these issues are clearly important, the paucity of global attention given to the world’s biggest killers e NCDs e is distressing. NCDs are currently estimated to kill around 36 million people per year, accounting for 63% of all deaths worldwide.10 And tobacco is one of the most serious culprits e one in six NCD deaths is caused by tobacco use.11 In this vein, the Lancet NCD Action Group and NCD Alliance have proposed five priority interventions to reduce global NCD death rates, chosen for their health effects, costeffectiveness, low cost of implementation, and political and financial feasibility. Of the five interventions, tobacco control is identified as the most urgent and immediate priority.11 Tobacco use is expensive, both on individual and population levels. Tobacco use has been shown to play into the
cycle of poverty, particularly among those who can least afford to spend a significant portion of their annual incomes on a product that does not benefit the household. The economic costs of tobacco use to governments are equally substantial. In addition to the high public health costs of treating tobaccocaused diseases, tobacco use kills or disables many people in their most productive years, thereby denying families their primary wage-earners; it consumes family income that should be spent in the home; and it raises the cost of health care.12 In a larger context, it deprives nations of a healthy workforce.13 Tobacco users are less productive at work because their poor health raises the incidence of sickness absence. Health impact alone, then, makes tobacco control a critical topic for multilateral negotiation. However, there are many serious health threats for which a treaty approach has not been considered. Treaties are high-profile, powerful tools, but they are laborious and expensive to produce and resource-intensive to administer and implement. The decision to pursue a legally binding instrument as a public health tool requires not only that the health concern be serious enough but also that the topic and context be amenable to an international legal solution. There have been a number of marked successes in the use of law to address public health concerns, and these successes provide insight into how and when law is most effective. Broad vaccination coverage, the use of seat belts, and the removal of lead from gasoline and paint are considered positive achievements in public health, and all are accomplished through legislation or regulation. In each case, a community affects individual behavior and choice though its governance structure. And in each case, something tangible and under human control is made either accessible or inaccessible. In countries that have implemented laws like the examples above, vaccines, seat belts, and lead-free gasoline and paint are available, while it is difficult to enroll children in school without vaccination records, to buy or sell a car without a seat belt, or to purchase lead-based paint or gasoline. The laws concerning vaccines, seat belts, and lead are all domestic public health laws. In considering whether or not to use an international legal approach, the domestic sphere is important e that sphere is, of course, where implementation of a treaty takes place e but it is also essential for a health topic to be transnational, both in impact and in possible solutions. That is, to be effectively addressed by a treaty, a health concern must be present in more than one country and must be something that countries can exert control over and monitor by mutual agreement. For example, malaria clearly fits the first criterion, but the second is harder: though things like mosquito nets can be made available, no amount of regulation is going to stop mosquitoes from breeding, biting people, or moving across borders.a a
It is worth noting that despite these difficulties, countries have turned to legal instruments e regulations rather than a treaty e to structure their cooperation and coordination with regard to the international spread of disease. Specifically, the revised International Health Regulations, which are binding on 194 countries, aims to help the international community prevent and respond to public health risks that have cross-border implications and that may be mitigated by regulation, such as yellow fever, cholera, and SARS, among others. Please see WHO International Health Regulations, 2005 (second edition). Geneva: World Health Organization, 2008.
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This paper presents only a fairly simple set of analyses, but these basic precepts for international public health law do provide a framework for considering why tobacco control was an appealing topic for WHO’s first treaty. First, tobacco use is a serious health threat, the vector of which can be controlled using legislation (e.g., raising taxes or eliminating smoking in public places) that in turn influences individual behavior. Additionally, the transnational nature of the tobacco industry, cross-border advertising, and advertising and sales of tobacco products on the internet, as well as the illicit trade of tobacco products, are genuine multilateral problems for which individual national responses do not provide feasible answers. Tobacco in particular highlights the limitations of nationallevel health governance in a globalizing world.14 Coordinated multilateral approaches are necessary to implement meaningful tobacco control. A number of health issues besides tobacco control could satisfy those criteria. This suggests that other, tobacco-control-specific qualities or considerations must also have been part of the milieu that allowed the WHO FCTC to be developed. These include a positive cost/benefit ratio, a strong evidence and advocacy base, and political palatability. Science-based evidence was crucial to maintaining political will in bringing the WHO FCTC to fruition, and such evidence lent political legitimacy to the process of its negotiation and adoption.15 The large body of scientific evidence on the health effects of tobacco consumption, coupled with evidence that the tobacco industry knew its products posed public health risks and failed to warn consumers, created the opportunity for the global health community e including governments and a strong cadre of advocates, non-governmental organizations, and researchers e to come together on the issue of tobacco control. From 1970 through the adoption of the WHO FCTC in 2003, the World Health Assembly unanimously adopted 20 resolutions pertaining to tobacco control.16 These resolutions, which created global consensus on the evidence base for and cost effectiveness of tobacco control, were essential to developing the ripe time for initiating negotiation of a treaty. A ‘ripe time’ denotes that that the time is right or ‘fertile’ enough to produce fruitful discussions. However, ripe time does not mean that all diplomacy conducted within this time frame will be successful, merely that less ripe periods are less likely to result in success and more ripe periods are more likely to result in success.17 It is crucial that a level of optimism and momentum be retained by the parties for the entire period. The 1998 Tobacco Master Settlement Agreement18 in the United States contributed to this momentum, giving the public health community a very public and very lucrative win against what had been an almost indomitable opponent, the tobacco industry. The identification of cost-effective interventions to control tobacco was also key to maintaining political will for the development of a treaty. Tobacco control is relatively inexpensive to implement and, in cases such as well-designed tobacco tax structures, has been shown to increase governmental revenue while concurrently reducing prevalence. Governments were increasingly aware that tobacco taxes can generate huge financial benefits which can be used to contribute to the funding of other tobacco control initiatives as well as other health goals.
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As with all politics and policy, the evolution of the WHO FCTC was driven by a combination of well-timed, synergistic circumstances and determined advocates; strong political will from countries; and a good foundation of evidence. It is possible that a similar convergence will propel another NCD topic into treaty negotiations, though six years’ worth of data on the WHO FCTC’s implementation presents a new layer of consideration for any other proposed negotiation.
Implementation of the WHO framework convention on tobacco control The WHO FCTC is without question the most powerful tool the international community has to reduce the global NCD burden. With over 170 Parties to the treaty, its provisions can affect the lives of more than 87% of the world’s population. The treaty demonstrates the role and strength of international law as a tool for achieving global public health goals. The frameworkprotocol approach utilized in this public health instrument sets out “baseline international norms” for tobacco control, as well as institutional arrangements for global governance of tobacco.15 The treaty itself includes provisions spanning economics, law, environment, and good governance and highlights the importance of the involvement of both state and nonstate actors from not only the health sector but also other policy sectors such as trade, education, and law enforcement.14 The treaty confers legally binding obligations on its Parties, which must be implemented through effective national laws. Its provisions encompass both demand- and supply-side strategies. It also incorporates the four key pillars in any comprehensive tobacco-control programme: (1) preventing initiation of tobacco use; (2) promoting cessation; (3) protecting the public from exposure to second-hand smoke; and (4) tobacco product regulation.19 Effective tobacco control, when properly implemented and backed by strong national legislation and enforcement, has the power to save millions of lives. Implementation of just four of the WHO FCTC’s population-based control measures could avert an estimated 5.5 million deaths over 10 years in 23 low- and middle-income countries that experience a high burden of NCD deaths.20 Accelerated implementation of the WHO FCTC can only mean more successes for global tobacco control. In this vein, we next examine some of the key successes and challenges of WHO FCTC implementation.
Successes In addition to reducing tobacco use prevalence rates and changing cultural attitudes, in particular toward smoking, there have been strong achievements in implementing some of the core provisions of the WHO FCTC. The most prominent of these include the placement of health warning labels on tobacco products, the implementation of smoke-free places, and tobacco product taxation.
Warning labels The Guiding Principles of the WHO FCTC state that every person should be informed of the health consequences, addictive nature, and mortal threat posed by tobacco
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consumption and exposure to tobacco smoke.21 Article 11, Packaging and labelling of tobacco products, requires Parties to implement effective measures to ensure that health warnings and messages are provided on tobacco products sold within their jurisdictions within three years after entry into force of the WHO FCTC.22 Such health warnings are required to conform to specified characteristics, e.g., they must be large, clear, visible, and legible; they must cover no less than 30% but preferably more than 50% of principal pack display areas; and they must be rotated. In 2008, the Conference of the Parties to the Convention adopted guidelines to assist Parties in implementing the provisions in Article 11.23 Health warnings and messages on tobacco product packages are effective in increasing public awareness of the dangers of tobacco consumption24 and therefore encourage both reduction and cessation of tobacco use.25,26 Warnings that include pictures are more effective than text-only warnings,27,28 particularly in countries with high illiteracy rates. The size of the warning is also important, as larger warnings are more noticeable.29 A cost-effective component of tobacco control,28,29 warning labels have been introduced all over the world, and today, more than 1 billion people live in countries that require large graphic health warnings to be shown on every cigarette package.30 Warning labels on packaging also reduce the marketing effect of tobacco product packaging, making it more difficult for tobacco companies to reinforce brand awareness.30 A move toward generic, plain packaging on tobacco products would further decrease the ability of the tobacco industry to promote its products.31 Plain-packaging legislation has been proposed in Australia and is being considered in the United Kingdom.
Smoke-free places Article 8 of the WHO FCTC, Protection from exposure to tobacco smoke, states that “Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability” and requires Parties to implement effective laws to provide “protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places”.32 To assist Parties in meeting this obligation, the Conference of the Parties to the WHO FCTC adopted guidelines for the implementation of Article 8 that advocate for “the total elimination of smoking and tobacco smoke in a particular space or environment in order to create a 100% smoke-free environment” and maintain that there “is no safe level of exposure to tobacco smoke”.33 Non-smokers who breathe in second-hand tobacco smoke are recognized as being at risk. Exposure to second-hand tobacco smoke is estimated to have contributed to more than 600,000 deaths in 2004, about 1% of worldwide mortality.34 Ninety-eight countries have currently implemented some kind of policy requiring smoke-free environments; however, only 31 of these policies are fully comprehensive.30 Nevertheless, smoke-free policies at the subnational level are increasingly popular.12
Taxes Article 6 of the WHO FCTC, Price and tax measures to reduce the demand for tobacco, urges Parties to implement tax policies and
price policies on tobacco products and to prohibit or restrict sales to and importations by international travelers of tax- and duty-free tobacco products.35 Increasing tobacco product taxes and prices is extremely effective in reducing prevalence rates of tobacco use, particularly among the young and the poor, and can also generate significant increases in revenues.36 Increases in government revenues can contribute to increased funding of other tobacco control initiatives. More than 80% of all countries have taxation policies covering tobacco products30; tobacco excise taxes collect nearly US$ 167 billion globally each year.12 To assist governments in implementing effective tobacco taxation policies, WHO has published a technical manual on tobacco tax administration.36
Challenges As with any ambitious policy movement, implementation of the WHO FCTC has not been without challenges. Some challenges are inherent in the document itself; for example, the instrument is considered by some to cover too much or too little, to contain inadequate sanction measures, or to not appropriately address tobacco cultivation and crop substitution. However, as these provisions are intrinsic to the document, they are less amenable to resolution than are other challenges. Some of the external challenges are described below.
Negotiating protocols The WHO FCTC contemplates protocols in its text. Article 33, Protocols, provides the procedural route for adopting protocols to the Convention, and Article 13, Tobacco advertising, promotion and sponsorship, includes the forward-thinking provision that “Parties shall consider the elaboration of a protocol setting out appropriate measures that require international collaboration for a comprehensive ban on cross-border advertising, promotion and sponsorship”.37 At its first session, the Conference of the Parties to the WHO FCTC created two working groups to prepare templates for protocols on illicit trade in tobacco products and on cross-border advertising, promotion, and sponsorship of tobacco products.38 At its second session, the Conference of the Parties established an intergovernmental negotiation body for a protocol on illicit trade in tobacco products.39 The body was to submit a draft protocol to the Conference of the Parties at its fourth session. Progress has been slow and difficult. Despite concerted effort and substantial financial support from key Parties, the intergovernmental negotiating body was not able to finalize a draft protocol for consideration at the fourth session. The Conference of the Parties has extended the body’s mandate, and there is hope that a draft protocol will be submitted at the fifth session in 2012.
Enacting and enforcing advertising bans Article 13 of the WHO FCTC, Tobacco advertising, promotion and sponsorship, requires that each Party undertake a comprehensive ban of all tobacco advertising, promotion, and sponsorship, including cross-border advertising, promotion, and sponsorship originating from its territory, within five years after entry into force of the treaty for the Party. This provision has proven particularly difficult to implement. This is because
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although advertising campaigns can be a cost-efficient means of reaching large numbers of people, they can also be expensive.30 Furthermore, anti-tobacco advertising strategies are generally more effective when they are run over long periods. Advertising campaigns should run “for at least 6 months to affect awareness, 12e18 months to have an impact on attitudes, and 18e24 months to have an impact on behavior”.40 However, many tobacco control programmes are unlikely to have sufficient resources to run sustained campaigns.30 In addition, the tobacco industry often tries to prevent or limit anti-tobacco advertising campaigns, claiming that they are inaccurate and a misuse of government resources.30 At the moment, well over 100 countries should have implemented advertising bans, but only 19 have comprehensive bans on all forms of direct and indirect advertising.30
The tobacco industry The single largest challenge to WHO FCTC implementation is the tobacco industry, which continuously adapts its tactics to circumvent new laws and regulations controlling its activities. A recent study undertaken by WHO’s Tobacco Free Initiative of legal cases and negotiations related to tobacco product disclosures found that seven factors were repeatedly argued by the industry when opposing disclosure legislation: (1) lack of jurisdiction; (2) domestic property rights; (3) technical barriers to trade; (4) international intellectual property rights; (5) privacy rights; (6) burden; and (7) vagueness.41 In addition to invoking legal arguments to oppose regulation, the industry has been innovative in making tobacco products more appealing, using additives and flavorings to enhance their taste. More worrisome is the invention of electronic nicotine delivery systems (electronic cigarettes, or “e-cigs”), which deliver nicotine to the respiratory system without producing smoke. WHO has stated its concern over the safety and efficacy of this class of products, as well as the lack of any published studies of their health effects.42 There is every reason to believe that the industry will continue to press any advantage, create loopholes wherever it can, and continue to fight for its existence. In this effort, it will spend billions of dollars.
Building on the successes of and lessons learned from the WHO FCTC The WHO FCTC has raised awareness of the benefits of using legal instruments to achieve public health goals. Indeed, the achievements of the WHO FCTC have led to calls to translate its successes to other public health problems, in particular, other NCD risk factors, such as the harmful use of alcohol and diet and nutrition. Parallels are often drawn between tobacco control and alcohol control. There have even been numerous calls for a framework convention on alcohol control.43e47 However, many of the critical early factors that drove the negotiation of the WHO FCTC e including strong political will and a long history of multilateral resolutions e are not in place for alcohol. Additionally, some have noted that alcohol use “is more widely and deeply embedded in many parts of the world than tobacco use” and has been used much longer “than the 100 years or so that tobacco use has been embedded in high-
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income countries”.43 This may present a higher threshold for taking international political action to create legally binding provisions on alcohol control. There has been some movement to create “soft” international agreement on alcohol, though. In 2010 the 63rd World Health Assembly unanimously endorsed the Global strategy to reduce the harmful use of alcohol, which contains “a portfolio of policy options and measures that could be considered for implementation and adjusted as appropriate at the national level”.48 Among the policy options offered in the global strategy are a number that reflect the tobacco control model generally and the WHO FCTC specifically, including availability of alcohol (regulating alcohol sales and implementing age restrictions); marketing of alcoholic beverages (limiting or banning advertising, promotion and sponsorship); pricing policies (strategic taxation to reduce consumption); reducing the negative consequences of drinking and alcohol intoxication (providing health warning labels); reducing the public health impact of illicit alcohol and informally produced alcohol (regulating production, tracking and tracing products, enforcement and international cooperation); and monitoring and surveillance.49 Perhaps the global strategy, in combination with the strong public health advocacy movement in this area and the scientific evidence detailing alcohol’s damaging health effects that continues to accrue, will be the first steps in creating a foundation for moving toward negotiation on binding alcohol control measures. Public health advocates are also actively exploring whether and how policy interventions tested in tobacco control can apply to the food industry, particularly in monitoring and controlling industry practice.50 Further, tax and pricing strategies that clearly reflect the tobacco control experience are being proposed for sugar-sweetened beverages and snack foods to help begin to control the obesity epidemic.51 As with alcohol control, there are challenges inherent to controlling food and diet that create a more complicated, nuanced discourse than is the case for tobacco control. Specifically and in direct contrast with tobacco, while the wrong foods can be harmful, the right foods and appropriate nutrition are essential to life and must be available to all people. The recent high-level meeting of the United Nations General Assembly on NonCommunicable Diseases on 19-20 September 2011 provided an excellent opportunity to highlight on a global stage the need for further and fuller implementation of the WHO FCTC. Given this, there are concerns in many sectors, including food manufacturers, policymakers, and members of the public, that applying the lessons of tobacco control to other areas will result in expensive, heavy-handed legal restrictions that may adversely affect food availability.52 Anti-regulation is a consistent theme across the spectrum of NCD control work, and though it did not prevent success in tobacco control, food access has some more complicated aspects, so these arguments may frustrate efforts to move international diet and nutrition control toward legal negotiations. Despite the challenges, though, the World Health Assembly has also made strides forward in this area, endorsing the WHO Global Strategy on Diet, Physical Activity and Health in 2004.53 Here, too, the strategies often mirror those in the WHO FCTC, including promoting education, communication and public awareness; controlling marketing, advertising, sponsorship
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and promotion; providing informative labeling and health information; discouraging misleading descriptors and claims on food products; price, tax and subsidy measures; and monitoring and surveillance.53 While the very formal, highly negotiated treaty or framework convention/protocol approach of the WHO FCTC may not suit either alcohol or diet at this point, promising non-treaty instruments addressing NCDs now exist in global strategies and the foundations may be laid for developing global standards and regulations to implement them. For example, global standards or regulations on alcohol and food product packaging and labeling, as well as the advertising of these products, particularly in relation to marketing them to children, could help ease the NCD burden. Each step toward global standards and regulations will further pave the way for the possibility of generating international law in these areas. As evidenced by the tobacco experience, controlling alcohol and unhealthy food and drink through international legal instruments will require that the body of supporting scientific evidence, strong commitment from states, and dedicated support from a global network of non-governmental organizations continue to be fostered. Vigorous negotiations are required to ensure that a carefully balanced instrument is achieved that takes into account scientific, economic, social, and political considerations of what is to be controlled.43 Further, commitment e both political and financial e would be necessary not only in the negotiating stages but also in implementation.
Conclusion The WHO FCTC emerged from a sea of scientific evidence and political will to fight the tobacco epidemic and industry. Although the negotiation process was highly political and at times difficult, the clear evidence of the potential health effects and availability of cost-effective interventions, along with continued strong support from governments and civil society, made the inception of the treaty possible. The success of the treaty and the tangible benefits that have already been secured will positively influence the health of millions of people today and in the future. Benefitting from the tobacco control and WHO FCTC experience and translating those successes to other areas of public health e in particular, to other NCDs e will require concerted effort and may require some creativity; not every topic may be ripe for developing a treaty, but the foundations that may allow for future international negotiation, agreement, and movement forward with other types of international instruments are being laid. In The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, adopted by the UN General Assembly on 18 September 2011, governments recognized the seriousness of NCDs, acknowledged the WHO FCTC and similar instruments, and committed to concerted international cooperation to address NCDs.54 Though there was no call to develop other mutually binding instruments, the high-profile meeting and the presence of many heads of state perhaps demonstrates a new, increased political will to address the enormous health, social and economic burdens attributable to NCDs. There remain substantial challenges e political, economic and technical e but
using the law in innovative ways to bring about great improvements in global NCD control holds genuine promise that should continue to be explored, supported and furthered.
references
1. WHO. 10 facts on secondhand smoke. http://www.who.int/ features/factfiles/tobacco/en/index.html (accessed on 20. 07.11). 2. WHO. Tobacco fact sheet no.339, http://www.who.int/ mediacentre/factsheets/fs339/en; 2011 (accessed on 20.07.11). 3. WHO. World Health Assembly Resolution 49.17, International framework convention for tobacco control; 1996. 4. WHO. WHO Framework Convention on Tobacco Control (updated 2004, 2005). Geneva: World Health Organization, http://www. who.int/tobacco/framework/WHO_FCTC_english.pdf; 2003 (accessed on 20.07.11). 5. WHO. WHO World No Tobacco Day. Three ways to save lives. Geneva: World Health Organization; 2011. 6. Lee K, Goodman H. Global policy networks: the propagation of health care financing reform since the 1980s. In: Lee K, Buse K, Fustukian S, editors. Health policy in a globalizing world. Cambridge: Cambridge University Press; 2002. 7. Taylor A, Bettcher D. WHO Framework Convention on Tobacco Control: a global "good" for public health. Bull World Health Organ 2000;78:920e9. 8. Shattuck H, Roemer R, Connor S, Curran W. American Bar Association report (recommendations and reports): World Health Organization. Int Lawyer 1996;30:686e95. 9. Yach D, Bettcher D. The globalization of public health. II: The convergence of self-interest and altruism. Am J Public Health 1998;88:738e41. 10. Alwan A, MacLean D, Riley L, d’Espaignet E, Mathers D, Stevens G, et al. Monitoring and surveillance of chronic noncommunicable diseases: progress and capacity in highburden countries. Lancet 2010;376:1861e8. 11. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet 2011;377:1438e47. 12. WHO. WHO report on the global tobacco epidemic implementing smoke-free environments. Geneva: World Health Organization; 2009. 13. WHO Western Pacific Region. Health topics: tobacco. http:// www.wpro.who.int/health_topics/tobacco/overview.htm (accessed on 20.07.11). 14. Collin J, Lee K, Bissell K. The framework convention on tobacco control: the politics of global health governance. Third World Q 2002;23:265e82. 15. Magnusson R. Non-communicable diseases and global health governance: enhancing global processes to improve health development. Globalization and Health 2007;3:1e16. 16. WHO. WHA Resolutions 23.32 (1970); 24.48(1971); 29.55 (1976); 31.56 (1978); 33.35 (1980); 39.14 (1986); 40.38 (1987); 41.25 (1988); 42.19 (1989); 43.16 (1990); 44.26 (1991); 45.20 (1992); 46.8 (1993); 48.11 (1995); 49.16 (1996); 49.17 (1996); 52.18 (1999); 53. 16 (2000); 54.18 (2001); and 56.1 (2003). http://www.who.int/ fctc/about/wha_resolutions/en/index.html (accessed on 20. 07.11). 17. Greig M. Moments of opportunity: recognizing conditions of ripeness for international mediation between enduring rivals. J Conflict Resolution 2001;45(6):691e718. 18. National Association of Attorneys General. Master Settlement Agreement, http://www.naag.org/backpages/naag/tobacco/ msa/msa-pdf; November 1998 (accessed on 20.07.11). 19. WHO. WHO Technical Report Series 945. The scientific basis of tobacco product regulation. Geneva: World Health Organization,
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 8 4 7 e8 5 3
20.
21.
22.
23.
24.
25. 26.
27.
28.
29.
30.
31. 32.
33.
34.
35.
36. 37.
http://www.who.int/tobacco/global_interaction/tobreg/ 9789241209458.pdf; 2007 (accessed on 20.07.11). Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;70:2044e53. WHO. WHO Framework Convention on Tobacco Control (Article 4) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20.07.11). WHO. WHO Framework Convention on Tobacco Control (Article 11) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20 July 2011). WHO. Guidelines for implementation of Article 11 of the WHO Framework Convention on Tobacco Control (Packaging and labeling of tobacco products). Geneva: World Health Organization, http://www.who.int/fctc/guidelines/article_11.pdf; 2008 (accessed on 20.07.11). Hammond D, Fong G, McNeill A, Borland R, Cummings K. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control 2006;15(suppl. 3):iii19e25. Borland R. Tobacco health warnings and smoking-related cognitions and behaviours. Addiction 1997;92:1427e35. Fathelrahman A, Omar M, Awang R, Borland R, Fong GT, Hammond D, et al. Smokers’ responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine Tob Res 2009;11:248e53. Thrasher J, Hammond D, Fong G, Arillo-Santilla´n E. Smokers’ reactions to cigarette package warnings with graphic imagery and with only text: a comparison between Mexico and Canada. Salud Pu´blica de Me´xico 2007;49(suppl. 2):S233e40. Hammond D, Fong G, Borland R, Cummings K, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med 2007;32:202e9. Borland R, Wilson N, Fong G, Hammond D, Cummings K, Yong H, et al. Impact of graphic and text warnings on cigarette packs: findings from four countries over five years. Tob Control 2009;18:358e64. WHO. WHO report on the global tobacco epidemic warning about the dangers of tobacco. Geneva: World Health Organization; 2011. Freeman B, Chapman S, Rimmer M. The case for the plain packaging of tobacco products. Addiction 2008;103:580e90. WHO. WHO framework convention on tobacco control (Article 8) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed 20.07.11). WHO. Guidelines for implementation of Article 8 of the WHO Framework Convention on Tobacco Control (Protection from exposure to tobacco smoke). Geneva: World Health Organization, http://www.who.int/fctc/cop/art%208% 20guidelines_english.pdf; 2008 (accessed 20.07.11). ¨ berg M, Jaakkola M, Woodward A, Peruga A, Pru¨ss-Ustu¨n A. O Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet 2011;377:139e46. WHO. WHO Framework Convention on Tobacco Control (Article 6) (updated 2004, 2005). Geneva: World Health Organization, http://www.who.int/tobacco/framework/WHO_FCTC_ english.pdf; 2003 (accessed on 20.07.11). WHO. WHO technical manual on tobacco tax administration. Geneva: World Health Organization; 2010. WHO. WHO Framework Convention on Tobacco Control (Article 33, Article 13) (updated 2004, 2005). Geneva: World Health
38.
39.
40.
41.
42.
43. 44.
45.
46.
47. 48.
49.
50.
51.
52.
53.
54.
853
Organization, http://www.who.int/tobacco/framework/ WHO_FCTC_english.pdf; 2003 (accessed on 20.07.11). WHO. Decisions and ancillary documents (decision FCTC/ COP1(16) Elaboration of protocols). Geneva: World Health Organization. http://apps.who.int/gb/fctc/PDF/cop1/cop1_ 06_cd_decisionsdocumentsauxiliaires-en.pdf (accessed on 20.07.11). WHO. Decisions and ancillary documents (decision FCTC/ COP2(12) Elaboration of a protocol on illicit trade in tobacco products). Geneva: World Health Organization. http://apps. who.int/gb/fctc/PDF/cop2/COP2_07_CDDecisions-en.pdf (accessed on 20.07.11). Schar E, Gutierrez K, Murphy-Hoefer R, Nelson D. Tobacco use prevention media campaigns: lessons learned from youth in nine countries. Atlanta, GA: US Department of Health and Human Services; 2006. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. WHO. Work in progress in relation to Articles 9 and 10 of the WHO Framework Convention on Tobacco Control. Report by WHO’s Tobacco Free Initiative. Document FCTC/COP/4/INF.DOC./2. Geneva: World Health Organization, http://apps.who.int/gb/ fctc/PDF/cop4/FCTC_COP4_ID2-en.pdf; 2010 (accessed on 20. 07.11). WHO. WHO Study Group on Tobacco Product Regulation. Report on the scientific basis of tobacco product regulation: third report of a WHO study group. Geneva: World Health Organization; 2010. Casswell S, Thamarangsi T. Reducing the harm from alcohol: call to action. Lancet 2009;373:2247e57. World Medical Association. World Medical Association statement on reducing the global impact of alcohol on health and society. Chile: WMA General Assembly, http://www.wma.net/en/ 30publications/10policies/a22; 2005 (accessed on 20.07.11). American Public Health Association. A call for a framework convention on alcohol control, http://www.apha.org/advocacy/ policy/policysearch/default.htm?id¼1339; 2006 (accessed on 20.07.11). Jernigan D, Monteiro M, Room R, Saxena S. Towards a global alcohol policy: alcohol, public health and the role of WHO. Bull World Health Organ 2000;78:491e9. Lancet The. A framework convention on alcohol control. Lancet 2007;370:1102. WHO. WHA Resolution 63.13 Global strategy to reduce the harmful use of alcohol. Geneva: World Health Assembly, http://apps. who.int/gb/ebwha/pdf_files/WHA63-REC1/WHA63_REC1-P2en.pdf; 2010 (accessed on 18.09.11). WHO. Global strategy to reduce the harmful use of alcohol. Geneva: World Health Organization, http://www.who.int/ substance_abuse/alcstratenglishfinal.pdf; 2010 (accessed on 18.09.11). Brownell K, Warner K. The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? Milbank Q 2009;87:259e94. Chaloupka F, Davidson P. Applying tobacco control lessons to obesity: taxes and other pricing strategies to reduce consumption. Tob Control Leg Consortium; 2010. Mercer S, Green L, Rosenthal A, Husten C, Khan L, Dietz W. Possible lessons from the tobacco control experience for obesity control. Am J Clin Nutr 2003;77:1073Se82. WHO. WHA Resolution 57.17 Global strategy on diet, physical activity and health. Geneva: World Health Assembly, http:// apps.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf; 2004 (accessed on 18.09.11). UN. Political declaration of the high-level meeting of the general assembly on the prevention and control of non-communicable diseases. A/66/L.1. New York: UN General Assembly, http:// www.un.org/ga/search/view_doc.asp?symbol¼A/66/L. 1&Lang¼E; 2011 (accessed on 20.09.11).