The first international public health treaty negotiated by the World Health Organization (WHO) came into effect this February with the Framework Convention on Tobacco Control. The treaty, now ratified by more than 60 nations, is a milestone in international efforts to counteract alarming increases in rates of cigarette smoking, particularly in the developing world.

The treaty obliges participating countries to restrict tobacco advertising and sponsorship, require tougher health warnings on cigarettes and limit the misleading terms 'low tar' and 'light.' Other measures call for increased taxes and bans on smoking in public spaces. If implemented as stands, the WHO estimates that the treaty will reduce smoking rates worldwide by 1–2% per year. Whether that will happen depends on how well countries follow through.

The numbers also might not aim high enough. Canada has sustained an average 4.1 percent decline in tobacco consumption each year since 1983. Should other nations do any less? The outcome will depend on an infusion of money into the cash-strapped program and sustained international pressure as the treaty comes up for revision. While some countries have moved ahead rapidly, others, like the US, have not yet even ratified it.

The treaty has been signed by 168 nations, but each country needs to ratify the treaty for it to take effect for its citizens. In some countries this effort is lagging, due in part to lobbying efforts from tobacco companies. In Brazil, a major tobacco-growing nation, arguments have erupted over how the treaty will affect the economy. And China, which has 330 million smokers and a state-run tobacco company, has yet to ratify.

The treaty is designed to counteract some bleak estimates. Tobacco kills five million people each year, from cancer, heart disease, emphysema and other illnesses, according to the WHO—more than the 4 million killed by HIV. If smoking continues to increase at current rates, the number of deaths will double by 2010, with 70% of the victims in the developing world. Already one in five 13–15-year-olds worldwide is hooked, according to the WHO.

Much of this increase is fueled by transnational tobacco companies. In 2002, the word's three largest tobacco multinationals had combined revenues of more than $121 billion, according to the World Bank—and they are moving rapidly into new 'markets'. Last year, Philip Morris' international sales went up to 18% to $39.54 billion and in March the company announced plans to buy a leading tobacco company in Indonesia for $5.2 billion. Between 1993 and 1996, global exports of tobacco increased 42%—fueled in part by reduced tariffs negotiated in a 1994 trade agreement.

Just as tobacco marketing is an international endeavor, so should public health efforts be global. The US and many other developed countries have seen a steady decrease in smoking rates among men, due in part to tobacco control efforts. But while anti-tobacco measures may seem to be a part of life in high-income countries, they could be stronger and many parts of the world lag far behind.

Experts say the measures in the treaty that are likely to have the most impact include large increases in price and comprehensive smoking bans—which have gained momentum with research showing the toxicity of second-hand smoke. New York City's ban in 2003—combined with high taxes and public cessation efforts—led to an 11% decline in the number of smokers within one year, according to the city's Department of Health and Human Hygiene. Smoking bans have also been instituted recently in Singapore, Thailand, South Africa, Uganda, Italy and in India—where half of tuberculosis-related male deaths are caused by tobacco.

The treaty is thin on details and effective laws and enforcement will depend in part on how the WHO budgets money to implement it. Funds now are scarce, and negotiators say that less than $15 million would enable important programs such as sending experts to countries inexperienced in tobacco control. Several analyses have shown that putting money into tobacco control is one of the most cost-effective public health measures. That is not surprising in light of the costs of tobacco-related diseases, which tally up $76 billion per year in the US alone, according to the WHO.

It is not exactly clear what the US will choose to do. When the treaty first came under discussion during the Clinton administration, negotiators said that the government had told them to put teeth into the agreement. But in the last several years, the US has reportedly weakened the treaty at the negotiating table, particularly measures that call for banning smoking in public places and tobacco-related advertising. The head of the US Department of Health and Human Services signed the treaty last year, but President Bush has yet to send it to the Senate for ratification.

In the coming years, revisions or 'protocols' will emerge that could strengthen the treaty. And countries that ratify will have a say at the table. Future measures could include toughening international laws against smuggling, which the US government is particularly concerned about, and regulating advertising across borders.

The US—in the past and now—has had a large role in propelling increased smoking rates. For decades after World War II, for instance, the US exported hundreds of millions of dollars in cigarettes under the 'Food for Peace' program. Paradoxically, the country has also led the way with tobacco control research, and at the state level, in tobacco-related public health measures. The US has the expertise, influence and money—and the moral obligation—to become a leader in international tobacco control. But for the US and for many other countries, ratifying the treaty has to be the first step.