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While tobacco-control experts in many developed countries announce remarkable reductions in tobacco consumption, nutrition and physical activity experts in these same countries bemoan the growing epidemic of obesity. Food and physical activity differ substantially from tobacco in that they are essential to life. Whereas the goal with tobacco control is to eliminate all use, obesity control focuses on reducing some behaviours (excessive and unhealthy food intake) and increasing others (physical activity). On the other hand, both tobacco control and obesity control involve influencing complex behaviours. For example, many overweight people struggle with tendencies similar to smokers by compulsively ingesting food for gratification even though they have surpassed their nutritional requirements. Such similarities suggest that there may be some overlap between obesity control and tobacco control. This chapter builds on and updates previously published work in seeking to draw lessons from the successes of the tobacco-control experience that can be applied to efforts to reduce and prevent obesity.

This chapter reviews the evolving economic and social system sustaining the growing tobacco epidemic in order to identify how globalization is affecting the industry, governments, and tobacco control advocates. It is divided into four main sections. The first section recalls key historical events that led to the worldwide prominence of tobacco use and the global rise of tobacco-related death and disease. The second section examines scientific evidence regarding the health effects of active and passive smoking and reviews the globalization of the public health response to the tobacco epidemic. The third section describes the Framework Convention on Tobacco Control (FCTC) negotiating process and final treaty text. The fourth section analyzes some of the remaining major challenges resulting from working within a global system, in particular, those challenges associated with developing coherent domestic and international policies and the permanent need to anticipate the unintended consequences of national and global regulations. The chapter concludes by identifying new directions and resources for global tobacco control and predicting some of the main challenges that lie ahead.

The international public health community, led by the World Health Organization (WHO), as well as other governmental and non-governmental institutions, remain committed to the containment of the tobacco epidemic. This commitment was evinced by the entry into force in 2005 of the landmark global public health Treaty, the WHO Framework Convention on Tobacco Control (WHO FCTC). With the establishment of this legally binding instrument addressing a wide range of tobacco supply and demand measures, the fight against the global spread of tobacco use driven by the tobacco industry's exploitation of globalization is now rooted in a set of baseline international norms. This chapter outlines the manner by which the tobacco industry manipulates globalization in its attempt to derail public health programmes combating tobacco consumption; and describes the WHO's efforts in formulating counteractive measures to protect public health interests from that of the tobacco industry. Specifically, the chapter focuses on measures taken in relation to the WHO FCTC's provisions concerning the mitigation of tobacco industry interference and the strengthening of a global regulatory framework for tobacco products.

This chapter explores the linkage between investment law and international instruments protecting public health, focussing on the specific issue of tobacco control. Since the recent inception of the WHO Framework Convention on Tobacco Control, which has established cognitive and normative consensus for promoting global public health through tobacco control, states have gradually adopted a series of measures to comply with this convention. However, international investment governance risks undermining the goal of tobacco control, for example by facilitating access to tobacco products, increasing competition, and lowering tobacco prices. After analysing the relevant legal framework, this chapter explores the potential conflict areas between investment governance and tobacco regulation, and proposes some legal tools that might help reconciling the interests at stake. In particular, it proposes recourse to customary rules of treaty interpretation.

This chapter continues the story from the previous chapter. The Supreme Court held that a regulatory statute aimed at unsafe drugs and devices does not authorize regulation of a drug (nicotine) and a device (a cigarette) that the Court agrees are unsafe. And far more than most, this particular drug and device risked the life-threatening harms that administrative regulation was intended to rectify. Thus, the action shifted to Congress. The tobacco control negotiations of 1997–8 are reported in this chapter. The litigation that attempted to inflict large judgments on the tobacco companies had never succeeded in the past and, so far have not succeeded since then (with the sole exception of the cases brought by state attorneys general). Children are still taking up smoking at an alarming rate, and one-third of those who take up smoking could die from smoking-related causes.

This chapter discusses the legal and policy interventions for preventing and controlling tobacco use. It reviews legal authorities that affect tobacco use at the federal, state, and local levels, and considers key developments in tobacco litigation. The chapter discusses legal issues and controversies such as reducing youth access to tobacco, reducing exposure to second hand smoke, and the regulation of tobacco advertising and promotion.

This chapter discusses the issue of tobacco harm reduction. Tobacco harm reduction can be considered as one approach to reduce tobacco-caused mortality and morbidity, but should not be considered as the primary approach. To date the only known method for reducing population harm is to eliminate the use of tobacco products through prevention or cessation. Yet, in order to assess the potential public health impact of novel products being introduced onto the market, it is essential to continue to monitor and study the evolving characteristics of tobacco products. Some new products are advertised with either explicit or implicit claims of reduced exposure or health risks which are not evidence-based and which may mislead consumers into thinking they are using ‘safer’ or ‘safe’ products. In addition, some of these novel products are advertised to be used in situations where smokers cannot smoke which may contribute to sustained dependence and continued use of tobacco products. However, some of these products may lead to reduced health risks if smokers were able to switch completely to using these products and may lead to eventual cessation of all tobacco products.

Evaluation of the effectiveness of tobacco control policies at the population level has been limited by inadequate data sources, problems in measurement, and poorly conceptualized evaluation designs borrowed from clinical medicine with insufficient attention to differences in the nature of the interventions. This chapter presents a model for evaluating the evidence for the effects of population-based tobacco control interventions that allows for ongoing improvement and the capacity to build on the accumulated knowledge about intervention effects gathered by others. Much of the material is synthesized from a recent IARC handbook on methods for evaluating tobacco control policies. The chapter also provides some additional discussion of when particular intensities of evaluation are important, both before and after policy implementation, and further consideration of criteria for ranking the quality of evidence.

Tobacco control policy has evolved over time and will continue to do so. To every action by the tobacco industry there has been a reaction by public health authorities and vice versa. As a result there has been a continuing struggle between those committed to market expansion (the industry) and those committed to market shrinkage (public health authorities). This chapter considers the following issues: prevention of smoking initiation; management of addiction; regulation of the cigarette, the way it is sold, its nicotine content and its emissions; protection of non-smokers from second-hand smoke; public education and control of labelling and trademarks; disincentives to purchase (tax) and restrictions on sales to minors. The chapter will summarize what is, in effect, modern comprehensive policy.

This chapter discusses the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). The WHO FCTC is public health history in the making and has become a landmark for the future of global public health with major implications for the WHO's health goals. It represents a milestone for the global promotion of public health policies and provides new legal dimensions for international health cooperation. It corroborates the critical roles of international law in preventing disease and promoting health. While the WHO FCTC represents one huge stride forward, it is but a single step in controlling the tobacco epidemic. The success or failure of the Treaty remains highly dependent on country level implementation, and on how international, regional, and national players from different sectors employ it.

Litigation plays at least six different roles in tobacco control. First, the most common and least dramatic role is ordinary enforcement of tobacco-control laws. Second, too frequently governments enforce tobacco-control laws sporadically or not at all, creating the opportunity for NGOs either to bring law enforcement actions directly or to sue their governments to force them to do their job, depending on whether courts will permit NGOs to take such actions. Third, tobacco companies increasingly use litigation to thwart effective tobacco control legislation and programmes, typically arguing that constitutional provisions or other controlling law pre-empts such measures. Fourth, lawsuits and administrative proceedings have been brought by smoke-sensitive individuals against employers and places of public accommodation, seeking protection from second-hand smoke or compensation for illnesses caused or exacerbated by exposure to second-hand smoke. Fifth, many lawsuits have been brought by individuals, groups or classes of individuals, and third-party health care payers against the tobacco companies, seeking compensation for tobacco-caused illness, death, and/or out-of-pocket economic costs. Sixth, governments occasionally attempt to enforce general laws (e.g., against racketeering) against tobacco companies, alleging that deceptive and illegal practices by the industry have harmed the general public. Unlike ordinary law enforcement, these cases seek court orders requiring fundamental changes in the way these companies do business. Each of these roles has implications for social change. This chapter discusses each of these in turn, with the most attention devoted to the cases against the tobacco industry. It also looks at the role that legislation can play in encouraging or discouraging tobacco litigation. It concludes with a brief discussion of how tobacco control would have been different in the past in the absence of litigation, and how litigation may affect the course and success of tobacco control in the future.

This chapter provides a brief practitioners' guide to some fundamental principles of tobacco control advocacy in its core tasks of convincing politicians to act and supporting them when they do. Politicians, particularly health ministers, are of absolutely cardinal importance for the passage of tobacco control legislation. If a health minister is not interested in tobacco control, or sees it as a political liability, that legislation will not progress. The central dilemma of tobacco control advocacy is therefore how to persuade health ministers of the importance of tobacco control and then to try to extend that influence to the health minister's cabinet colleagues, without whose support legislation will not pass. If the government's political majority relies on the votes of a small number of independent politicians, these too will be critical to efforts.

This chapter provides an overview and introduction to the now vast data on the adverse health consequences of passive smoking, covering the risks to passive smokers, including the fetus, infants and children, and adults. In about three decades, progression has been made from the first studies on passive smoking and health to definitive evidence that passive smoking causes disease. The evidence derives from not only epidemiological studies, but studies with biomarkers documenting that tobacco smoke inhaled by non-smokers delivers doses of toxic components and metabolites to target organs. There are also animal studies and extensive data on patterns of exposure. The strength of the evidence and its public health implications have been a strong force for motivating tobacco control policy.

For decades cigarette companies have successfully harnessed the power of branding to transform a simple product into a powerful tool that projects a complex set of images and personality traits to its user. Beginning with California's large-scaled anti-smoking campaign in 1990 — the first in twenty years — tobacco control efforts began to counter and deconstruct cigarette brand imagery. In 1998, the Florida ‘truth’ campaign extended earlier efforts by California and Massachusetts to counter tobacco brands by developing a tobacco control brand aimed at youth and intended to take market share away from cigarette brands. Evidence shows that tobacco countermarketing campaigns are effective in reducing youth and adult smoking, and emerging literature suggests that the brand value or equity of youth tobacco counter brands adds value to the campaigns. However, branding in tobacco countermarketing campaigns remains uncommon.

In this chapter, I chronicle how India negotiates the FCTC by mapping how the globalization of tobacco in the 1980s and 1990s shaped India’s interests vis-à-vis multilateral tobacco control, how the key domestic institution, MOHFW, grappled with India’s tobacco use problem, which was itself the legacy of tobacco going global, and sought to address it through COTPA and how their intent for tougher tobacco rules, with support from interest groups advocating tougher tobacco control, shaped India’s approach at FCTC negotiations and ratification.

This chapter first discusses the connection between tobacco control and human rights. It describes human rights obligations, vis-à-vis tobacco control, and examines in closer detail the connection between the Framework Convention on Tobacco Control (FCTC) and human rights. In particular, it looks at the role of human rights in monitoring and enforcing the FCTC. The second part of the chapter examines industry arguments against tobacco regulation while showing how they are flawed from a human rights perspective. Finally, the chapter identifies new areas of concern in tobacco control and human rights, such as industry arguments based on trade and investment law and connections with intellectual property rights.

This chapter discusses the impact of tobacco control campaigns on heart disease mortality and morbidity, focusing on the California tobacco control programme. Smoking reduction is considered the quickest, most effective prevention strategy for heart disease morbidity and mortality. The most effective components of tobacco control programmes are taxation of cigarettes, passage of clean air legislation, and media campaigns focusing on tobacco industry manipulation and second-hand smoke.

This chapter addresses the evidence concerning the impact that fiscal policy has on health behaviour and the relative effectiveness of fiscal policy and other interventions. The evidence will be set out first for the case of tobacco control and will consider results from the literature and the application of fiscal policy in the UK. This will address questions relating to the impact of fiscal policy on overall smoking prevalence and on socio-economic inequalities in smoking prevalence. This example will then be compared with the situation relating to alcohol and other health behaviours. Before turning to the evidence, the following sections consider the theoretical basis for fiscal interventions and how evidence of the effectiveness and efficiency of such interventions is generated.

The chapter tells the story of the paradigm shift in tobacco control in the Los Angeles County Department of Public Health. Early tobacco control efforts focused on health education and voluntary policy adoption. A 2004 appraisal identified gaps in the Tobacco Control & Prevention Program’s organization and capacity. Subsequently, a new framework was developed emphasizing the primacy of adopting and implementing legislative-based tobacco control policies. The chapter presents key elements of the framework including organizational changes, capacity-building efforts, and the development of a structured model for policy change. Dramatic increases in tobacco control policy adoptions were observed following program restructuring. The chapter concludes with key lessons learned providing a model for other communities and health departments transitioning to a tobacco control policy adoption and implementation focus.