Of the thousands of international treaties in force, virtually none address global health issues.

That made the 2003 adoption of the Framework Convention on Tobacco Control, an international treaty designed to stem the global epidemic of tobacco-related death and disease, all the more remarkable.

Conceived originally by a couple of public health activists, the concept of an anti-smoking treaty was eventually embraced by the World Health Organization (WHO) under the leadership of former Director General Gro Harlem Brundtland.

Although WHO initiated and drove the process of treaty negotiations, it was thanks to the efforts of tobacco control groups worldwide that a treaty with any teeth was eventually adopted. The activist groups played a crucial role in turning aside the efforts of the multinational tobacco companies -- and the countries that sought to defend the industry's interests, notably the United States, Japan and Germany -- to undermine and eviscerate the treaty during the negotiating process.

Combating the Tobacco Epidemic
WHO initiated the first formal negotiating session of the Framework Convention on Tobacco Control (FCTC) in Geneva in October 2000. Less than three years later, on May 21, 2003, the 192 member nations of the World Health Assembly, including the United States, voted unanimously to adopt the FCTC. The treaty will go into effect once 40 countries ratify it. By the end of 2003, more than 80 countries had signed the treaty and 5 had ratified it.

Public health experts say the FCTC represents the most ambitious worldwide effort so far to address the global tobacco epidemic, which WHO projects will soon become the world's leading cause of death, killing 10 million annually by the year 2025. Seventy percent of these deaths will occur in developing countries.

Once the treaty goes into force, and countries that have ratified it implement the tobacco control measures it mandates and encourages, the global tobacco industry will face new limits on how it conducts its deadly business.

Some of the key provisions included in the final version of the FCTC are: a comprehensive ban on tobacco advertising, promotion and sponsorship (with an exception for countries, such as the United States, which deem such a ban unconstitutional); a ban on descriptors which misleadingly convince smokers that such products (for example, by use of the term "lights" in Marlboro Lights) are safer than standard cigarettes; and a mandate to place rotating warnings on tobacco packaging, covering at least 30 percent of display areas, with encouragement for even larger, graphic warnings. The FCTC also encourages countries to implement smoke-free workplace laws, take measures to address tobacco smuggling, and increase tobacco taxes.

The FCTC did not deliver everything that activists hoped for. While certain measures, such as the advertising ban, are mandatory, many others are not. And certain issues, such as tobacco industry liability for its products and the principle of prioritizing health over trade, are skirted or only vaguely addressed.

By nature, framework conventions are intended to provide a general structure for more specific protocols -- subsequent agreements on specific issues -- to follow. Public health activists therefore say the FCTC is a work in progress -- a beginning, not an end, to international collaboration in dealing with the tobacco industry and the global public health catastrophe it has wrought.

The FCTC negotiations dramatically elevated the profile of tobacco and health issues, placing tobacco control on the agendas of governments around the world. The FCTC process facilitated the education of the public and key decision makers in many branches of government concerning the full scope of the tobacco epidemic, the nature of the industry that is responsible for it, and global best practices in tobacco control. It has given many low-income countries, particularly in Africa, the political will to stand up to the tobacco industry. And it has inspired a diverse array of nongovernmental groups to become more engaged in tobacco control work.

Driving the Negotiations
Non-governmental organizations (NGOs) in many ways functioned as the conscience, "moving spirit" and technical support for the FCTC process, championing a strong treaty at all steps along the way. They attended negotiation meetings, drafted optimal language, lobbied and provided technical assistance to government delegates to FCTC negotiations, issued briefing papers on key negotiating issues, and reported on the treaty negotiations.

Two global networks of NGOs coordinated FCTC lobbying efforts worldwide: the Framework Convention Alliance (FCA), a grouping of more than 200 organizations in 93 countries, and the Network for Accountability of Tobacco Transnationals (NATT), made up of more than 75 groups in 50 countries. There is much overlap between the two networks" membership and activities. Both alliances" activities were marked by impressive cooperation and collaboration across borders between NGOs in the North and South, mostly facilitated through e-mail communications -- and driven by a common interest in reining in a rogue industry dedicated to pillaging global health in the pursuit of ever-increasing profits.

The members of the FCA, says Judith Wilkenfeld, director of international programs at the Washington, D.C.-based Campaign for Tobacco-Free Kids and a member of the FCA's steering committee, "represent the diversity of interests and concerns caused by tobacco around the world. Working together we created a powerful lobbying force by working on a basis of total consensus and complete respect."

From the outset of the treaty negotiations, NGOs were intent that the FCTC should serve as a floor, not a ceiling for international tobacco control standards. There was widespread recognition, however, that a weak, poorly defined treaty would be used by the tobacco industry to justify weak tobacco control measures at the national level. It was imperative that the draft text of the FCTC be as strong and specific as possible.

"NGOs' impact proved to be invaluable, particularly in providing credible information to delegations that were eager for assistance and support in crafting strong public health positions," says Shane Bradbrook, director of Aparangi Tautoko Auahi Kore (ATAK) - Maori Smokefree Coalition (New Zealand) and an FCA Steering Committee member.

NGOs provided this basic but vital information in a variety of ways, including direct lobbying during negotiation breaks and in-country meetings, lunchtime seminars featuring various tobacco control experts to which delegates were invited, and the distribution of reports, issue papers, and daily bulletins.

According to Akinbode Oluwafemi of Environmental Rights Action/Friends of the Earth, Nigeria and a NATT Steering Committee member, specialized briefings for African delegates played an important role in bolstering the region's support for a strong FCTC, after some initial resistance.

"There was a collective realization by the African countries' delegates that tobacco was, after all, not benefiting the economies of the poor African countries, while at the same time the tobacco industry was increasingly focusing on Africa for their future market," agrees Muyunda Ililonga, executive secretary of the Zambia Consumer Association (ZACA) and also a member of the NATT Steering Committee.

A key lobbying resource during the negotiations was the FCA's "FCTC Bulletin," a daily publication designed to both communicate with and apply pressure on the FCTC delegates. The Bulletin highlighted issues at the heart of the negotiations, provided information on recommended best practices, exposed industry tactics worldwide, and reported on governments" negotiating positions.

Mr. Butts goes to Geneva
Beyond educating delegates and the public on the FCTC, tobacco control groups focused their efforts on countering the efforts of the tobacco industry and its governmental allies to derail the negotiations.

NGOs tapped their creativity to find unique visual ways to remind delegates of their obligation to protect public health from the tobacco industry. In Geneva, NGOs kept a "death clock" running, marking the number of people killed by tobacco worldwide since the beginning of negotiations, to underline the urgency of the situation. Activists dressed up in a "Mr. Butts" costume to deliver petition signatures in favor of a strong FCTC to country delegates. And banners were displayed which depicted the many victims of tobacco around the world.

NATT members collected examples from around the world of industry efforts to direct country negotiating positions and then used them in their lobbying and media advocacy efforts. The Zambia Consumer Association (ZACA) discovered, for instance, that the tobacco industry had contacted the Zambian delegates by phone in Geneva to lobby certain positions in their favor. The example was exposed in Infact's 2003 report "Treaty Trespassers: New Evidence of Escalating Tobacco Industry Activity to Derail the Framework Convention on Tobacco Control," which sought to further dissuade governments from entering into dialogue with the tobacco industry.

NATT also organized a series of International Weeks of Resistance to Tobacco Transnationals leading up to several FCTC negotiating rounds, to advocate for a treaty strong enough to halt the tobacco industry's long interference in public health policy around the world. As part of the International Weeks of Resistance, NATT members around the world organized demonstrations at Philip Morris and British American Tobacco facilities, held press conferences and educational events, and screened founding member Infact's documentary "Making a Killing: Philip Morris, Kraft, and Global Tobacco Addiction" on television.

From the outset of negotiations, NGOs worried that the United States would work to prevent the majority of the world's countries from moving forward in a collective effort to address the global tobacco epidemic. As the negotiations were winding up, with no sign of the United States retreating from its obstructionist role, NGOs switched from a 'shape up" to a 'ship out" message, calling on the U.S. delegation to remove itself from the negotiations altogether.

In the United States, e-mail, fax and telephone campaigns were launched targeting the head of the U.S. delegation Kenneth Bernard. Leading up to the final round of negotiations, Infact and Essential Action, a project of Essential Information, the publisher of Multinational Monitor, held a demonstration featuring a 10-foot high pack of Marlboro cigarettes labeled "U.S. Pack of Lies" in front of the U.S. Department of Health and Human Services, complete with gigantic cigarettes bearing phrases like "U.S. Fronts for Big Tobacco," "U.S. Hijacks Global Health," "Weapon of Mass Destruction" and "Tommy T: Tobacco or Health?" --designed to highlight the double standard between the U.S. government's rhetoric on protecting the world from terrorism versus its inaction in controlling the deadly tobacco industry.

During the final FCTC negotiating round, NGOs lined up in front of the room where the final draft was being deliberated and held signs calling for the U.S. delegates to go home. According to Hatai Chitanondh, a Thai delegate who worked closely with NGOs, this action had an immediate noticeable effect, "Every time I had proposed the wordings for health over trade from the second negotiating round up to that moment, the U.S. delegate would come up and rebut me strongly. But that time, they kept their mouth shut, choosing to have [a small group of other tobacco-friendly nations] confront me instead."

One clever NGO pressure tactic was the daily announcement in the Framework Convention Alliance's FCTC Bulletin of "Orchid Award" and "Dirty Ashtray Award" honorees -- countries that had done the best and the worst jobs of championing public health the previous day. The first thing that many FCTC delegates did upon receiving their copy of the bulletin was to flip it over to the back page to see who got the Dirty Ashtray Award and the reasons why.

"Some governments took the awards seriously enough to complain to the FCA and even to raise it during the plenary session," notes Mary Assunta of Malaysia and a member of FCA's Steering Committee, "The purpose of the Dirty Ashtray award was to single out governments that were being obstructive to the process or promoting a terrible position, and nobody wanted to be singled out as a villain."

NATT had its own award of dubious distinction for governments and tobacco companies that tried to sabotage the FCTC, the Marlboro Man Award. The award was a useful tool in drawing media attention to governments and transnational companies" efforts to derail the negotiations.

While the U.S. delegation, a regular recipient of the Dirty Ashtray and Marlboro Man Awards, evidenced no public concern with being singled out, the awards served to further highlight the country's isolation in its extreme positions and to empower smaller countries to stand up to the last-ditch efforts of the U.S. to weaken the treaty text.

The combined NGO efforts buttressed the smaller countries that were supportive of a strong FCTC. "The U.S. made every effort to water down the FCTC until the bitter end," says Thailand's Hatai Chitanondh, "but we developing countries stood firm in the face of bullying. People always came to me and urged, �We are not afraid of them (the United States, Japan, and its allies). We"ll fight hard. Although we are small, they are outnumbered by us.""

At the very last hour, the United States did join the rest of the world's countries in supporting the FCTC text. The key deciding factor -- intensive NGO lobbying or a "go ahead" signal from the tobacco industry, after shrewdly calculating the political benefits of the U.S. supporting but not ratifying the FCTC -- remains a mystery.

When asked by Washington Post reporters for an explanation for the surprise shift in the U.S. position, U.S. Secretary of Health and Human Services Tommy Thompson gave only a short, cryptic response: "someday I will tell you."

Fast Forward for Tobacco Control
While the final FCTC text has been adopted by the World Health Assembly, the ultimate effectiveness of the FCTC will largely be determined by the number of countries that sign, ratify and ultimately abide by it, as well as the strength of future protocols under it.

For many countries, even those with strong tobacco control measures already in place, the FCTC holds promise for further control of tobacco industry activities, particularly tobacco advertising and promotional campaigns.

"Although Thailand has many strong laws and regulations already," says Hatai Chitanondh, "we can benefit greatly in several areas, for example, cross-border illicit trade of tobacco products that one country cannot suppress by itself, cross-border advertising, such as satellite telecast of tobacco-sponsored events, and Internet sales and ads."

"The FCTC will fast-forward Malaysia into enacting much stronger legislation and plugging loopholes in our current weak regulation," says Mary Assunta, "For example, Malaysia has the dubious reputation of being the world capital for indirect advertising and brand-stretching activities by the tobacco transnational companies. The FCTC will put an end to these forms of promotions."

Benefits have been realized already, thanks to the heightened attention on tobacco control flowing from the FCTC negotiations.

"Many countries have not waited for formal adoption and have introduced legislation to remedy the ills highlighted during the negotiations," says Judith Wilkenfeld. "In fact, they have past the United States in tobacco control -- the United States no longer has the gold standard in regulations. Large, effective warning labels are mandated in Brazil, Canada, Belgium and Thailand. The European Union, Brazil and Israel have banned the terms "light" and "low." Norway and Ireland are both smoke free, and Canada has some of the most progressive product regulation laws in the world."

For countries with very few tobacco control measures, the FCTC could facilitate huge strides forward in efforts to address the rising tide of tobacco-related death and disease.

"In Nigeria, the FCTC will serve as an advocacy tool in getting the government to make tobacco control a priority," predicts Akinbode Oluwafemi, "The convention is a global initiative and as such, easier to market to Nigerian policy makers. And as a comprehensive instrument, once the government signs and ratifies it, the FCTC shall bring a total review of the ineffective national tobacco control law currently in place."

Time will tell just how effective the FCTC is as a tool for strengthening tobacco control legislation worldwide. Public health activists agree that continued NGO vigilance will be necessary, to monitor the implementation of the FCTC and tobacco industry efforts to interfere with this process, assist with the initiation and development of treaty protocols on specific topics, and ensure that adequate financial resources are raised to support these efforts.

Anna White is coordinator of Essential Action’s Global Partnerships for Tobacco Control, which links groups in the United States and Canada with groups in developing countries. Essential Action is a project of Essential Information, the publisher of Multinational Monitor.