Before the disclosure of the recent tobacco settlement in the USA, William Novelli, Head of the Campaign for Smoke Free Kids, commented in a key note address on the occasion of "World No Smoking Day" earlier this year in Washington that "there will be no true justice and no end to the tobacco wars until the American and other tobacco companies change the way they do business worldwide, not just in the United States".

Disclosure about the ongoing settlement talks and the final release of the contents have jolted the global tobacco control community into action in ways that have previously not occurred. The most profound impact of the early release of the settlement outcome may well be the massive global media attention being devoted to the need for tobacco control to extend across national borders. Tobacco control is at last being framed correctly as a global issue, not merely a domestic one.

The first indication from the stock market about shareholders' response to the proposed settlement was summarized in the Sunday Observer of 22 June 1997. In their headline it was stated that "BAT share price rises as total 369 billion dollars pay-out take sting out of smoking action". When the industry supporters are happy, global public health must suffer.

In this presentation I will highlight key concerns with regard to global consumption of tobacco, indicate how new forms of globalization and action are receiving attention, briefly outline the context in which the settlement talks occurred in the USA, and consider how we can use the fact of these discussions as a means to advance global tobacco control.

Previous speakers in this session and many presenters during the entire conference will have highlighted the rapid increases in global consumption that the world is experiencing. This rapid increase in consumption is matched by slow progress in global tobacco control. Daily reports in the media provide further information about expanding trade, marketing, consumption and tobacco deaths. What is less well reported has been the reduced support for global tobacco control in financial terms.

With major exceptions being Canada's leadership and support for the International Tobacco Initiative and World Bank programming, new sources of funding for tobacco control that focus on the global increased impact of tobacco have not been forthcoming over the past decade. To be explicit, no major USA or other foundation or donor from a bilateral or multilateral agency provides significant support for global tobacco control.

At this years' World Health Assembly in Geneva many delegates expressed frustration about what they considered to be slow progress in achieving tobacco control in the face of rapid progress in expanding tobacco trade. Finally, there has been a serious lack of engagement between the public health fraternity and the World Trade Organization or UNCTAD with regard to the global implications of expanding trade. This has been at a time when Ministers of Trade have entered into agreements that could be used to restrict tobacco trade on public health grounds, but do not.

Many of these concerns have led to important actions by tobacco control advocates epitomized by a recent open letter to the European Heads of State by Joe Asvall, Regional Director, WHO EURO. Last month he called on all countries to appoint intersectoral committees at cabinet levels to discuss the trade, finance, agriculture, education and health implications of tobacco control. He specifically called upon heads of State to persuade their finance ministers to increase tobacco tax regularly and use a portion of it to fund tobacco control. He also urged a ban on all forms of advertising and promotion, and called upon national governments to control tobacco smuggling.

WHO's major response to the global threat has been to develop an International Framework Convention for Tobacco Control. Again Canada has played a pivotal role, hosting a meeting in Halifax over the weekend to accelerate action in this regard. Unfortunately the proposed Framework Convention is virtually unknown even among major tobacco control groups and leading tobacco control advocates. The success of the Convention requires global mobilization, and demand and debate by nongovernmental organizations if it is to be successfully adopted by all countries, and finally if it is to be implemented and monitored adequately. The preparation for the Convention needs to move out of the shadows and into the broad spotlight of public debate where, as with mobilization for the Convention on the Rights of the Child, the development of the Convention itself would have a massive, mobilizing effect on world public opinion with regard to tobacco control.

If we move from the global to the USA scene we see a profound difference. There has been considerable progress in tobacco control in the USA. Large tax increases have been seen in a few States over the last few years, the latest being the one dollar per pack increase in Alaska which will partly be used to fund public health initiatives. The National Cancer Institutes' ASSIST Programme has yielded new knowledge and information about how best to advocate successfully for tobacco control at the local level. Substantial financial support for the Campaign for Tobacco Free Kids has played a key role in moving the agenda in the USA and focusing a Presidential Campaign on the question of stopping kids from ever starting. In all, it is estimated that around 350 to 500 million US dollars are annually available for domestic control.

Against this backdrop of progress have been specific actions that are not in the usual list of national tobacco control strategies. These actions have really pushed the USA settlement talks to the level they are at now. These include the fact that thirty-two States are suing the tobacco industry for the harm they cause to smokers; several class action suits, among them the largest being tens of thousands of airline officials suing the industry for the health consequences of passive smoking. In addition five hundred plaintive suits are awaiting trial in the Courts. At the federal level, the FDA recently announced it planned to regulate nicotine, a decision that was challenged in a North Carolina court and upheld. The Federal Trade Commission plans to act against Joe Camel and we still hold out the possibility of Grand Jury indictments of tobacco industry executives who perjured themselves in Congressional hearings.

It is crucial to understand the shortcomings of the settlement talks. Cigarette prices and the proportion of the cigarette price being used for tax in the USA are among the lowest in the world. As can be seen from Figure I, the packet price in the USA is around $1.83 with only 29% going to tax, compared to figures of well over $3 to $4 in other OECD countries. In those countries, well over 50% and as high as almost 80% of the pack price constitutes tax for the government. The cheapness of cigarettes in the USA has not been addressed in the settlement talks by the tobacco control advocates, but certainly has been taken into consideration by the tobacco industry who realize that they can make up for any increased costs imposed upon them by simply raising the price of their cigarettes. Clearly, it would have been preferable for a massive tax increase to be enacted by Federal or State officials, that would go into the public purse rather than into the profit line of the tobacco industry.

In the closing days of the settlement talks there was the first hint that the settlement would not achieve its major stated objective: namely, reducing consumption of cigarettes globally. The media headlined a story 10 days prior to the terms of the settlement being announced with the statement that "a settlement could exacerbate public health threats in the developing world". At the same time Michael Pertschuk, a doyen of the tobacco control movement, and a well known USA public health lawyer, warned the public about "making deals with the devil" and documented his own thirty years experience of "big tobacco's tricks". He went on to urge those involved in the settlement to "remember future public health goals and not to leave the third world vulnerable".

I will not go through the terms of the settlement. Needless to say we all appreciate that in addition to tax, the global aspects of tobacco control have been ignored. This is despite the fact that the USA is by far the major exporter of cigarettes worldwide, accounting for almost a quarter of such exports in 1994. Data in Figure II underestimates the USA's true impact, given the enormous amounts of exports occurring through USA owned multinational company factories in eastern and central Europe and elsewhere. It is important to note that the USA, UK, Germany, Netherlands, Brazil, Singapore and China account for almost 80% of the world's exports of cigarettes. If we express the data differently, as is shown in Figure III, one gets a slightly different view. I have calculated here the number of cigarettes exported per hundred domestically consumed. The figures for the USA are falsely low and are corrected in the next table. The data gives the impression that in some countries such as Singapore, Netherlands, UK as well as Germany, and to a lesser extent Brazil and the USA, tobacco is a major source of export revenue. The figures for the Netherlands for example, show that for every hundred domestically consumed cigarettes, two-hundred and fifty-six are exported. The figures are above two hundred for the UK and reach one thousand two-hundred and fifty in the case of Singapore.

We need to understand more clearly the dynamics of global tobacco trade, who benefits in the end, and whether it is really the country or the multinationals based in a few select countries who should be targeted. The Director-General of WHO in his response to the ongoing settlement talks called for such a global analysis when he commented that "tobacco use and its ensuing consequences, is a global heath problem which requires a global solution".

The global nature of the problem, as opposed to the individual actions of countries, is shown by the data in Figure III where the sales of cigarettes by major companies in 1993 are indicated. Philip Morris and BAT each account for well over 10% of global sales. Seven companies operate out of five countries. These five, USA, UK, Japan, Korea and South Africa, in addition to the exporting countries mentioned earlier, need to be the subject of intensive tobacco control attention. NGO action is needed to ensure that such countries practice globally what they attempt to do domestically.

It is going to be the tobacco corporate lobby in these and a few other countries that will do its upmost to stop adoption of an effective Framework Convention for Tobacco Control. It will be these countries that will do their best through their trade delegations to ensure that the World Trade Organization does not exclude tobacco from its list of products that should be subject to the usual protection that trade liberalization brings.

Returning to the USA and the settlement talks, a major challenge to the tobacco control movement world wide is to develop a rationale for global action that will be applicable for the USA and for other countries that might yet embark on the settlement path. In this respect the settlement discussions have certainly raised the spectre of similar approaches being followed in the major exporting countries. A requirement will be to have in place demand for litigation and strong pressure by the NGO movement in that country combined with health ministry concern about the impact of tobacco. The last point is vital and emphasizes the importance that sound national epidemiological, economic and public opinion data has played in the USA in supporting policy development.

The rationale for global action seems to rest on three simple principles. First, one needs to apply the best national policies and strategies worldwide. In this respect, the settlement talks assume that USA control measures are the best, when in fact they fall short of the world's best control programmes. An alternative to the settlement approach would have been merely for Congress to adopt what are widely accepted as standard WHO recommendations approved by the USA repeatedly during resolutions of the World Health Assembly. This approach was well outlined by Neil Collishaw earlier.

Second, we need to ensure that there is coherence between model domestic policy and global action. This implies that a country that accepts a model approach should ensure that its multinationals fulfill the same criteria in all countries in which they practice. This principle has been respected with regard to asbestos, and recently we have seen it applied in the USA with regard to labour conditions and the manufacture of running shoes and clothing.

Third, there is also a need for countries to protect their citizens and tobacco companies from multinationals based elsewhere who seek to market and advertise their products in countries with lower standards of regulation.

With regard to the settlement, one would hope that the USA will support the development of an International Framework Convention by providing both financial and human resources; and by its support of public health goods that support tobacco control, particularly as they relate to research, global surveillance and human and institutional capacity to boost public health capacity in tobacco control. This principle of providing support for international public health goods is accepted and receives attention with regard to infectious diseases. Given the massive and future rising impact of tobacco control, the USA and other countries need to be consistent with regards to their practices globally in respect of infectious and non- infectious diseases.

Further, the USA needs to ensure that the World Trade Organization agreements are phrased to support the International Framework Convention. By having adopted legislative and regulatory approaches it will already be in a position to work with WTO to ensure that tobacco disputes no longer result in easy access being gained by multinationals to developing countries. Finally, and as was explained, with regard to current pricing of cigarettes in the USA, it is essential that part of a settlement include increasing the price of cigarettes and using extra revenue for public health.

The point about WTO was emphasized by the head of UNICEF, Carol Bellamy, in her statement of the 15 May 1997, when she stated that "there was an urgent effort needed by the international community, including WTO, to develop a global strategy to treat tobacco products commensurate with the harm they cause beginning with prohibitions on all direct and indirect tobacco advertising and promotional activities aimed at children and young people".

The only caution I would add relates a concern by Sir Richard Doll, way back in 1951, when on the occasion of his first discussion of the results of the follow-up to the British doctors' study a tobacco industry spokesperson urged him to focus on stopping children from starting rather than trying to stop smokers from quitting. I believe that this has been a repeated suggestion by the industry in an attempt to divert attention from the reality that we have 1.1 billion smokers in the world. Chris Murray, in a speech at the First Global Forum for Health Research at WHO last week, indicated that of the 8.4 million tobacco deaths expected in 2020, 2.9 million deaths will occur as a result of cigarettes consumed before 1997; 0.5 million deaths will occur in future smokers and 5 million deaths will occur in current smokers. Providing more aggressive means of encouraging smokers to quit would not only improve the quality of their lives but would have an enormous snowball effect on accelerating progress with regard to the attainment of overall tobacco control goals including the attainment of future smoke-free generations. A focus on preventing children from starting will only improve tobacco survival well beyond 2020.

In conclusion, I believe that the settlement talks provide a global wake up call for all involved in tobacco control. The most important implications seem to be the need for us to bring trade lawyers, economists and media experts as a matter of urgency into our fold

to strengthen what has to date been primarily a public health and medical approach to what is fast becoming an issue of global trade, human rights and global health equity. Failure to act decisively and globally against tobacco will mean that hope of achieving Health for All in the Twenty-first Century will itself go up in smoke!