 Welcome and thank you all for joining us this afternoon. I'm Steve Morrison, Director of the Global Health Policy Center here at CSIS. We're delighted today to be able to issue the new paper we commissioned at the end of summer, authored by Tom Boyke, titled Beyond Engagement, The Future of U.S. Engagement on International Tobacco Control. Tom has put together an important, provocative, cogent, and very timely piece of work. We're very grateful that he took this on, gave it such care and careful thought. We'll start this event momentarily in asking Tom to walk us through the paper's core argument and take 15 or 20 minutes to do that. And then we're going to move to a roundtable discussion on some of the key issues. And then we will invite you to join us in that conversation. This is part of a larger effort here at CSIS to become more active and more visible on issues pertaining to tobacco control and more generally to non-communical diseases. And we will have a series of high-level speakers coming through the course of next year speaking from different walks and different perspectives on these issues. In April of next year, we will be convening and we're fixing the dates here. We're going to convene for a major conference that will bring together senior representation from the Obama administration, from WHO, and from some of the other constituencies that have been most involved and committed on global tobacco control. So please stay tuned. We're finalizing which dates in April work in that respect. Tom Boyke is a visiting fellow at the Center for Global Development here in Washington where he investigates the legal and ethical issues that arise during the discovery, development, and delivery of essential medical technologies to the developing world. He served at the U.S. Trade Representative's Office where he led negotiations with the Koreans and Chinese on international property rights issues pertaining to pharmaceuticals and biomedical technologies. He has been a Fulbright scholar in South Africa with a focus on HIV AIDS treatment issues, access issues, holds a bachelor's degree in biology and history from Columbia University and a law degree from Stanford. A year ago, he produced an excellent paper on international food and drug safety issues that we commissioned and published here, which was quite impactful and we're honored and delighted that he's joined with us again in putting a second and excellent paper together. We're also delighted to have our other three distinguished guests here today who have agreed to join the roundtable discussion that will follow Tom's presentation. Tim McAfee has come from Atlanta from CDC and we're very grateful that you and your colleague, Kristen McAul came today for this event. Tom is an MD and MPH who joined CDC in September as director, as the new director of the CDC Office on Smoking and Health. He has a very distinguished and long career as a clinician researcher and public health evaluator. Since 2003, he has served as the chief medical officer for free and clear. He also helped found and serve on the board of directors of the North American Quit Line Consortium. Here in the United States, he's been at the front edge of multiple efforts to upgrade programs including the state of Washington's multi-pronged tobacco control efforts and designing various research and data collection initiatives. He is a co-investigator and principal investigator on multiple research studies that focus on questions relating to the effectiveness and dissemination of cessation programs, both in medical systems and government sponsored quit lines. We're joined also by Rosa Sandoval from the Pan American Health Organization. For the past seven years at PAHO, she has served as the specialist in tobacco control responsible for monitoring and evaluation of the WHO Framework Convention on Tobacco Control in the region of Americas, as well as providing technical support to member states. She's a public administrator trained at the Maxwell School at Syracuse University and served in various other duties in ministries in the Peruvian government. We're joined also by my colleague here at CSIS, Charles Freeman. Charles holds the Freeman Chair in China Studies at CSIS. He concentrates on the political economy of China with a special focus on trade and economic relations. He served as Assistant U.S. Trade Representative for China Affairs and served prior to that as a Legislative Counsel for International Affairs in the U.S. Senate. He's currently also a Senior Advisor to the Maclaurde Associates and serves on the Board of Directors of the National Committee of U.S.-China Relations. He is a JD from Boston University and a wonderful colleague here. So with that, I would again thank you all for coming and I would turn to and welcome Tom Boyke to present your paper. Thank you. This is working. Great. Thank you all for coming on...first, thank you, Steve. And then thank you all for coming on Elite Friday afternoon on a gorgeous day to talk about U.S. engagement on international tobacco control. I feel like this is a day in part of the Washington calendar where you normally would announce a firing or a tax increase or something. But actually, the latter is something I will be proposing here. The former is a potential consequence of this talk, but we'll see how it goes. Before getting started, I want to thank Steve Morrison and CSIS for the kind invitation to do this paper and this event to speak with you today. It has been a pleasure working with Steve and with Suzanne, Caroline, and Julia and the rest of the CSIS team. I also want to acknowledge the people who provided input and comments on this paper, some of the key people. And those include Doug Betcher and his team at the WHO, Kristen McCall and Samira Asmet, the CDC, Kelly Henning at the Bloomberg Initiative, and Brooke Cashman and Larry Gaston at Georgetown. Lastly, I want to thank the Center for Global Development, which is my home institution. Nancy Birdsall, Bill Savodoff, and Cindy Prieto in particular for their input and generosity on this project. So I agreed to do this paper because I was interested in what the consequences of the 2009 FDA domestic regulations would be for US international trade policy and global health policy around tobacco. And in thinking through that issue, I ran into three questions, which I didn't have a satisfying or easy answer to. The first is, what is the US government doing currently on international tobacco control? The second is, why should the US government do more? What is the case for increased US engagement on international tobacco control? And if the US government were to do more, what would it be? These questions became the subject of my paper and I try to answer them in this presentation today. But before getting to those questions, let me give you a little bit of background on the current state of affairs of the global tobacco epidemic. Tobacco use is the leading cause of adult disease and premature death worldwide. There are 1.2 billion smokers globally, which is 1 third of the adult population. 700 million children, which is 40% of all children, are exposed to secondhand smoke at home. Tobacco use is on the rise in low and middle income countries driven by increasing incomes, trade liberalization, and intensive marketing. Tobacco use is linked to the onset of a spectacular array of diseases, including cancer, respiratory, cardiovascular diseases, childhood illnesses, pregnancy, complications, strokes, you name it. Accordingly, the WHO has estimated that more than five million people a year die from tobacco use. That's actually more than HIV, tuberculosis, and malaria combined. If those trends persist, 8 million people will die by 2030 from tobacco use. And 1 billion people total in the 21st century. 80% of those deaths will occur in developing countries. But it's not just the loss of life. There are dramatic social and economic consequences to tobacco use as well. Tobacco is the top, or tobacco related disease is the top health expenditure in many developing countries. Those costs consume scarce resources and limit the ability of health systems to address infectious diseases and other threats. Tobacco use also consumes household budgets, Rob's families of the primary wage earners, and hinders economic development. The American Cancer Society estimates that tobacco use imposes $500 billion a year in costs on the world economy, which is approximately three times more than countries raised from tobacco taxes per year. There are many global health threats that we do not know how to prevent, particularly in resource settings. Tobacco use is not one of them. Tobacco control works. It is evidence based and it's cost effective. It has succeeded in developing countries like Alike, like Bhutan, South Africa, Poland, Thailand, and elsewhere. The WHO Framework Convention on Tobacco Control, which entered into force in 2005, provides a blueprint for comprehensive tobacco control and a platform for policy coordination and development. It is one of the most widely subscribed treaties in the world, with 171 parties representing 87% of the world's population. The Framework Convention requires its parties to implement specific domestic tobacco control strategies to reduce the supply and demand for tobacco products. The WHO, in consultation with or with the support of the Bloomberg Initiative, developed the Empower Strategy, a package of evidence based, actionable, measurable strategies for the implementation of the Framework Convention. Despite its widespread adoption, however, the Framework Convention implementation, particularly in low and middle income countries and tobacco control in general, in those countries is lagging. A 2009 WHO report revealed that less than 10% of the world's population is covered by any WHO recommended measures to reduce tobacco demand. 90% of the world are without protection for tobacco industry marketing. 95% of the world's population live in countries where cigarette taxes represent less than 75% of the retail price. And only 9% of Framework Convention member countries mandate smoke free bars or restaurants. Now part of the reason for that slow implementation has been fierce industry opposition and the limited resources, governance and capacity of the countries involved. But part of it must be attributed to the design of the Framework Convention itself. The Framework Convention itself prioritizes inputs specific tobacco control measures and policies over outcomes, reduced tobacco use, prevalence. The Framework Convention does not include or did not involve providing resources, incentives and technical support for low income countries, low and middle income countries to implement it. Perhaps accordingly most of these low and middle income countries have adopted the prescribed measures that encountered the least industry resistance. Educational programs and prohibition on sales to minors rather than the strategies like increased excise taxes, advertising bans and smoke free legislation that has proven the most effective at cutting tobacco use. So this brings us back to our first question, which is with that background in place, what is the current US government engagement on tobacco control? Well, the US has a long history of leadership domestically on tobacco control. It was an early mover on banning cigarette advertising on television and radio, warning labels, forbidding smoking on commercial flights and the science around tobacco addiction. US cities and states, New York City and California in particular have led away with groundbreaking and effective tobacco control programs. In 2009, President Obama signed the Family Smoking Prevention and Tobacco Control Act, which empowers the FDA to regulate the domestic manufacturer labeling advertising and sale of tobacco products. Just yesterday, the FDA proposed new graphic warning labels, an example of which you see on the slide. While more remains to be done, US domestic tobacco controls have cut the percentage of American adults who smoked in 1965 from 42% of adults smoked in 1965, and in 2008 that was cut down to 19%. In contrast, unfortunately, US engagement on international tobacco control has been quite limited. On January 18th, 2001, President Clinton issued an executive order instructing US executive branch agencies to take, quote, strong action to address the potential global epidemic of diseases caused by tobacco use. Nearly 10 years later, however, the US is one of a small number of countries that have signed but not ratified the framework convention. In 2009, US funding for global health was $8.3 billion while the funding it dedicates to international tobacco control was a little less than $7 million. Most of that support comes through programs at the Centers for Disease Control and Prevention and the US National Institutes for Health. Tim is going to describe CDC's efforts in depth. So I will just say now that CDC works with WHO and the Canadian Public Health Association to conduct and support tobacco surveillance in low and middle income countries. Surveillance and monitoring are the bedrock upon which evidence-based, effective tobacco control programs are developed and implemented. And by all accounts, CDC's contributions have greatly improved the reliability of survey data and the validity of its statistical analyses. These efforts cost the CDC less than $3 million in 2009, which represented less than 3% of its overall tobacco control budget. NIH's Fogarty International Center has a program on capacity building and training for low and middle income countries. That program provided $37 million in 25 research grants between fiscal year 2001 and 2012. Undoubtedly, a global tobacco control also benefits from spillover effects from US in funding to the WHO generally, as well as NIH research on tobacco addiction and cessation. US development agencies, however, to date have implemented almost no programs on international tobacco control. The record on US trade since the 2001 executive order is mixed at best. On one hand, the Office of the US Trade Representative, of which I am an alumnus, was able to resist strong congressional pressure, including the holds on many of its political appointees this year to refrain from suing Canada over its new tobacco control laws. On the other hand, the US has compelled China as a condition of its 2001 WTO accession to agree to reduce tariffs on imported cigarettes and eliminate non-tariff barriers on foreign cigarette sales. Nearly all pending and active US free trade agreements reduce tobacco tariffs. All US bilateral investment treaties extend additional protection for tobacco-related investment. The BITS, the Bilateral Investment Treaties in particular, have facilitated the establishment of multinational tobacco companies, manufacturing facilities in low and middle income countries, which has allowed them to evade tobacco tariffs and also exercise increased influence over local policy. Which moves us to our second question. So what? Why should the US do more? And I think in an environment of tightening budgets and many competing global health demands, it's a legitimate question. It is not enough, in my view, to say the US should increase its support for international tobacco control just because it is a morally compelling problem, although it is. It should be acknowledged that the US engagement on tobacco control has several challenges. The first is that with the significant exception of tuberculosis, most tobacco-related diseases are non-communicable. In other words, the health of US citizens does not depend on the health of other country's citizens with respect to tobacco. Tobacco requires sustained and coordinated interventions, which are difficult to marshal. The tobacco epidemic is at its worst in emerging economies, China, Russia, India, Brazil, and Indonesia, which have the resources to counteract this rise. Finally, many still perceive tobacco use as a consumer choice, involving a legal product, despite study after study that shows the dangers of second-hand smoke and that most smokers start smoking in their youth and underestimate the risk of addiction and its consequences at that point. This analysis, however, doesn't adequately represent all of the US's interests in global tobacco control and the framework convention. US leadership in global health is a rare area of political consensus in increasingly partisan times. US investments in global health are visible, they are concrete, they save lives and improve the credibility of the US worldwide. In a recent speech before the UN, President Obama cited global health and development as not only US moral objectives, but strategic and economic imperatives as well. Secretary Clinton made a similar speech recently in which she cited humanitarian interests and economic social development as being key drivers of US investment in global health. Two global health threats can compare with the human and economic toll of the tobacco epidemic. Improved tobacco control is central to the realization of US global health priorities on disease prevention, on tuberculosis, on maternal and child health, and health systems strengthening. The Global Health Initiative outlines three criteria for making its investments. The first is that it will target what has worked in the past. The second is that it will look for areas in which there are existing platforms on which to build. And the third is they will look for areas that have potential strong partners. Again, few areas meet this criteria as well as tobacco control. Tobacco control programs are cost effective and have succeeded in developing countries alike. The framework convention is widely adopted. And the WHO, the Bill and Melinda Gates Foundation, Bloomberg, and a bevy of very well-established NGOs all work on anti-tobacco control efforts and would be useful to US partners. The third area is the US engagement might be able to prevent critical expansions in the tobacco epidemic. Many people see Africa as the next big market for tobacco use. Women have historically smoked less than men in developing countries, while recent surveys have shown that they now smoke at the same rate as boys in 60% of countries. The WHO, the Gates Foundation, Bloomberg initiatives, the campaign for tobacco-free kids and others are all trying to stop this expansion. Increased US engagement can improve their chances of success. The US has interest in the framework convention even if it doesn't ultimately ratify it. Failure to implement the framework convention undermines its utility as a vehicle for global tobacco control, as well as the WHO's ability to lead on global health challenges in general, which the US needs it to be able to do. Last is that inaction on international tobacco control has negative consequences for the US. In the absence of effective coordination, countries have adopted uncoordinated approaches to taxation and regulation. These have created trade tensions and disputes, including the recent dispute against US over its ban on clove cigarettes at the WTO, and increased potential for cigarette smuggling, which has been tied to organized crime and terrorism. This brings us to our third and last question. What should the US do more? I mean, assuming the US should do more, what should it be? Now, ideally, increased US engagement on international tobacco control would begin with ratification of the framework convention. That would certainly be the clearest demonstration of US leadership and commitment on global tobacco control and to the WHO. However, it should be recognized that this is unlikely to occur in the near term. President Obama is on record supporting ratification, but the administration has not submitted the framework convention to the US Senate. This likely reflects a sour political climate, preoccupation with domestic matters, and a general wariness of treaties more than a specific lack of interest in the framework convention. Last time I checked, the administration had, in fact, only submitted four treaties to the Senate for ratification during its administration so far, and only one of those has been ratified, which is a tax treaty with France. This should not stop the US, however, from working with the WHO, partner governments, and non-state actors to achieve the treaties potential. Increased US support for implementation of the framework convention in low and middle income countries would accomplish many of the same objectives as ratification, showing increased US commitment and leadership on the issue, and actually do more to improve international tobacco control since the US is compliant with the framework convention as it is. In this paper, I argue for a four-part strategy of how to do that. The first is to make global health a priority. If global health and disease prevention are US priorities, then international tobacco control must be as well. The Obama administration should recognize international and tobacco control as a key component of the global health initiative and make it its signature initiative on non-communicable diseases in advance of the 2011 UN summit on that issue. There should be improved global health and trade policy coherence. Now, trade negotiations have actually a constructive role to play on tobacco, reducing tobacco subsidies and increasing international coordination on tobacco regulation. The US should refrain, however, from seeking or granting tobacco tariff reductions and exclude tobacco-related investment from future trade and investment agreements with developing countries. These countries simply do not have the tax regime and the tobacco control systems in place to handle the change. Finally, the US should work with relevant foundations and NGOs to convince multilateral and bilateral development agencies to similarly prioritize tobacco control. The second recommendation is improving resources. Successful tobacco control programs require adequate and predictable resources. Despite recent commitments by the Bloomberg Initiative and the Gates Foundation, international tobacco control is severely underfunded, particularly in developing countries. 17 countries represent 99% of the government spending on tobacco control. Nearly 4 billion people live in countries that spend less than $20 million total on tobacco control. New sources of funding are needed. The US should seek a G20 commitment to institute a surtax on tobacco consumption to fund global tobacco control programs, particularly in developing countries. The surtax should be modest on a per-product basis. WHO analysis recently showed that a 5% per-packed tax in the high-income countries would generate $4.6 billion. That would more than quadruple the current budget for global tobacco control. The tax should be temporary. Low-income countries have the ability and it's important for their tobacco control programs to levy tobacco taxes. The purpose of this fund should be to jumpstart framework convention implementation and to provide the expertise needed to build domestic taxation capability. Make no mistake, imposing such a surtax would not be easy and would require high-level leadership. However, G20 countries generally have such excise taxes in place already and there has been little downward pressure on them. In fact, many countries and many US states are increasing them. Effective tobacco control requires will and approaches that address local conditions. US should build incentives for an outcome-driven bottom-up approach to tobacco control that complements the policy-driven top-down approach of the framework convention. There would be a number of possibilities for such incentives. But the one I think that is most promising is the one the Center for Global Development's cash on delivery aid concept. The basic concept here is that a funder and recipient enter into a contract in which the parties agree on an outcome, in this case some measure of reduced tobacco use prevalence, and fix a payment for each unit of confirmed progress. An independent third party collects data and verifies the progress on the outcome. Here the outcome should be linked to existing studies already done through the CDC and the WHO. Once progress is verified, the funder pays for improved outcomes. The arrangement is transparent and public. The recipient is free to spend the payment according to its needs. This approach builds local institutions and creates an incentive for local solutions by providing unrestricted rewards. It aligns local leaders, not just the health ministry, with achieving tobacco control. And tobacco control is a very multi-sectoral problem. And it would also increase, of course, demand for technical insistence on tobacco control and surveillance. The last recommendation on that I put forward in this background paper is that tobacco control requires a mix of expertise and inputs, taxations, customs, monitoring, and evaluation that historically have not resided at the WHO. The US should work with G20 partners to scale up and improve those capacities. The US should focus for its part in its areas of comparative advantage. Surveillance, taxation, product regulation, monitoring, and evaluation. US should leverage activities that are already going on at foundations and NGOs and seek to coordinate with other donors like the Global Fund and the UN Development Fund for Women. In conclusion, this is now a important moment in tobacco control. The scientific evidence around tobacco use and secondhand smoke causing terminal and disabling diseases is undeniable. Tobacco programs have succeeded in developing countries alike. Framework convention is widely subscribed. The Empower strategy works. And the 500 million multi-year commitment from Bloomberg and Bloomberg Initiative and the Gates Foundation have injected sorely needed resources into tobacco control. With the cost effective strategies I outline in this background paper, I think US engagement can transform this momentum into sustainable progress against an otherwise expanding tobacco epidemic. Thank you very much. Thank you very much, Tom. I think you've laid out very well the ambiguous point that we're at where there's been much progress with the FCTC, with the Bloomberg and Gates and WHO initiative, and with this gathering sense that this is a winnable battle, that it's a best buy, that the economic price tag for GDP is mounting, and that the demographic and epidemiological transition point that's underway right now is also very powerful, a very powerful form of data and economic cost projections that are moving people to think about, OK, what next? Where do we go next in our approaches? And so thank you very much. You've put a couple of ideas out there that are complex and debatable, the tax issue, and is that feasible? Who leads? How do you form the coalition? The cash on delivery proposal, those two core elements. And I think we can come back and talk a little bit more about those and about how one might move those and how feasible and what kind of political strategy would bring that. But let's set that for the moment aside because I'd like to hear from our other three guests in opening and filling out the picture a bit. And I'd like to begin with Tim, Rosa, Charles. And Tim, I'd like you to talk for a few minutes about CDC's perspective and how and why it sees this as winnable. We heard this from Dr. Frieden when he was here in delivering a major speech on the full spectrum of prevention interventions that he sees as so critical on global health. He made this case. It'd be good to hear a little bit more. It'd be good to hear about the special capacities and assets that CDC brings to the table because you have been so central for such a long time as an institution and looking forward how you see CDC supporting an engagement that would move things forward, that would reinforce the GHI, that would work collaboratively with some of the other key institutions, including the World Bank. Those are several big questions. But if you could open up and speak for a few minutes on how you see that. And I'd like to move to Rosa and ask her to talk a bit about the PAHO perspective. Tim? Great. Thanks very much. Can you hear me? Not there? Excellent. And first, before I dive into that list, I just want to congratulate Tom on an incredible, really, I think, intellectual achievement, having done such a good job, but succinct, but very powerfully describing what the dire circumstances really that we face in the 21st century, if we don't do more, and I think, in many ways, that's the most important thing that we have to do is that we have to convince ourselves and other leaders in global health, but not just global health, the other sectors that are thinking about these issues, both globally and in the countries, that this is something that we cannot afford to be, essentially, in the US spending 1,000th of our global budget on. One of the things that attracted me to come to CDC and head the Office of Spoking Health was our historic commitment and the commitment of Dr. Frieden to doing more in the global arena. But listening to Tom describe this, I'm also, essentially, I'm both proud and embarrassed that what we are doing is such a substantial fraction of all the effort that's happening in the US because so much more should be done. So at CDC, we've got a lot to think about because we're responsible for the health both around the classic things like infectious diseases, but increasingly also non-infectious diseases, everything from traffic accidents to maternal and child health, et cetera. So one of the things that we've done over the last couple of years is to try to focus, to really step back and say, what are the things that would really make a difference in the United States? And in order to get on that list, which now has about five or six things on it, the characteristics are that it has to be something that's important, that's having a significant impact on the health of the US population. But it also has to be, essentially, actionable. There has to be something where we have some tools where we can actually do something about. And there have to be evidence-based activities that we know work that are not fully implemented. And then finally, we have to have some way to measure whether we're being successful or not. And when you look at those things, tobacco basically percolates right up to the top. And again, I'm not going to go through the same arguments that Tom did internationally domestically. Suffice it to say that despite the fact that we have gone from 42% prevalence down to 20%, it's still the number one preventable cause of death in our country. And we have flatlined over the last four or five years in terms of dropping prevalence, both in adults and in youth. So we aren't done here either. So what CDC doing about this globally our primary activity currently, if you look at the empower model that was briefly laid out where you have monitoring tobacco prevalence and tobacco control activity, that's what we've focused on globally because we've built up a lot of capacity over the past decades in the US about that. And then over the past 10 years have been working to systematically both apply that in some countries around the world and also to begin disseminating essentially the technology for how one goes about doing this kind of ongoing surveillance. So we've worked with WHO in countries to create a global tobacco surveillance system, have assisted over 160 countries conducting youth surveys. And this is an incredible operation where we've mostly looked by going to schools themselves, training local staff on how to administer these surveys. And then also more recently have also been doing this with school personnel and health care students in health care. And then we've also been working more selectively around adult surveillance, particularly with help from the Bloomberg Foundation, where over the past few years we've been looking at 14 of the key countries in the world that for which tobacco is the largest problem and the cover of the largest segment of the world. And I'll just briefly tell you a few things that we found. This is, we're just completing the 14 countries and we'll probably see things in 2011 about the aggregate information from these countries. But just earlier this week, the Russian Federation released the results of their global adult tobacco survey. And this is helping to kindle a very strong response on the part of the Russian government around the release of these figures, which found basically that Russia is at the head of the pack that they wish they weren't. That they have the highest adult prevalence of smoking of any country in this group of 14. And that give you a couple flavors from the adults. China, which is fairly close to Russia in male smoking, it also has the largest gap around knowledge. That is the country where there's the least perception in the population that smoking is bad for the smoker or the exposure to environmental tobacco smoke is bad. But you also pick up interesting things, like even in Russia over 80% of the population believes that advertising should be banned. That the tobacco industry should not be able to advertise. Even more than almost three quarters of smokers think advertising should be banned. So this type of information is helping all these different countries with drill down information. We're starting to get into second cycles and third cycles and fourth cycles, particularly with the youth surveys that's helping out. One of the most disturbing things that the youth survey has found for the 21st century is that unfortunately in 70 countries where we have both youth and adult survey information, 58 of them showed that cigarette smoking for girls is as high or higher than the current rate of women. So rather than driving us down, we're looking at the potential for an increase in smoking in women as girls age into the population. In terms of what we can do, I'm trying to recall everything that you'd asked, but in terms of what we think we can do, well, there's the other five letters in the empower model. And CDC's had a lot of experience over the past 20 years working with the 50 states, the territories, and the tribal entities in really helping them to figure out what more they can do with their regional resources to try to take a comprehensive effect to decreasing the effects of tobacco use in their populations. So essentially we've been resource constrained at our capacity even though we're getting more and more requests from specific countries to try to do more for countries around taxation policies. How do you work through all the arguments that refer for taxation policies for secondhand smoke? What are the tools that you can use to convince your governmental entities, your private entities, your NGOs, that you won't cause economic hardship by eliminating secondhand smoke exposure in public places? All these sorts of things are very, very strategic and some of this is going on, but it's kind of catch as catch can and that's where your core recommendation that there needs to be some way that we figure out to make available more technical assistance and more support is gonna be really, really critical. And I think the will is there and we need to figure out some ways to do this. Just a couple of practical examples of this. One of the problems that we struggle with around tobacco is that because it's more of a non-communicable disease than communicable and it's less of a non-communicable, people just don't frame it up as a disease, it's buried, it's hidden in statistics and people don't think about it when somebody dies of heart disease or even lung disease, but we have some clear, easy wins where for instance tuberculosis, which is significantly impacted by smoking status, both becoming infected with tuberculosis but then the course of the disease is affected dramatically by smoking and so it's essentially completely illogical if you're doing a routine, repetitive kind of monitoring, you're giving people drugs, you're setting up this big infrastructure in Africa to do all this stuff and if you're just functionally ignoring the fact that somebody is smoking, it makes no sense at all. So I think we're starting to do some work and there's a lot of good stuff that's beginning to happen in that particular arena to help with that. Internal and child health is another great example where there's smoking during pregnancy is a major contributor to particularly preterm labor and other negative outcomes and this is something again where we're working hard to have routine prenatal care, it just doesn't make sense to try to not embed addressing smoking in that kind of element. I did just wanna, are you okay for just a couple more points? Sure. How are we doing? I wanted to, the one other point I would make I think around Tom's thesis around the 5% surtax is that we have not done a good job in the developed countries of figuring out how to use revenue that's come in from tobacco taxes to fund tobacco control and in the US we've actually gone backwards in the last two years. The states have lost about almost a third of their funding in the last two years for tobacco control, disproportionately diminished funds for state tobacco control relative to the larger state budgets. So it's related to the recession but it ain't just the recession and this is in many states, this happened concurrently, 20 states increased their tobacco taxes in the last two years. One state, South Carolina, the state that had the lowest tobacco tax in the country is the only state that provided even a penny towards anything related to tobacco control. So we're in a very kind of strange position around this and so I think that that's an approach to tobacco taxation that perhaps we should think twice about exporting to the developing world. If this is an almost unique area where actually if they institute the prime policy at the policy level that we're proposing which is to increase taxation, they simultaneously have at their fingertips the capacity to fund tobacco control in a manner that's almost unprecedented because it only takes a tiny fraction as you've illustrated with the five billion from a five cent tax. This applies in Thailand as a great example of this where they instituted an 83% excise tax on cigarettes only took 2% of a tax surcharge that they collected for health promotion and then used a fraction of that 2% to apply towards tobacco control and they've been much more successful because they essentially took the bull by the hands and actually used tobacco tax revenue to try to improve health. So with that I think I will wind down and let's go on. Thank you very much. Rosa, could you describe for us the perspective of the Americas in terms of where you see progress, where you see the unfinished business, what's the attitude with respect to prioritizing tobacco control among member states because so much of this comes down to perceived sovereign best interest and you're in the position of seeing the big picture of the Americas and the way this issue has played through over the last seven years. So if you could paint the picture for us a bit. Just from the creation, Tom, for your article I really enjoyed reading it. The FCTC has been my life for the last seven years so it was very nice to read your article and especially to see concerns that we working on tobacco control in low-middle income countries have, especially the need for more technical assistance from those countries with more expertise in general in tobacco control or in specific issues. Coming back to your question, well in the Americas the panorama is like you described it. Many countries have ratified the FCTC. We have 35 countries in the Americas and 27 have ratified it. That means eight have not the US among them unfortunately and but widely ratified in a region which means then that many countries have mandates to implement. You may know the FCTC has deadlines for certain articles to be implemented. The first article whose deadline expired, I don't know if that's the verb I should use for that but you get the meaning, was article 11 on packaging and labeling, health warnings, the news that we just had on the US in the recent days and that article is supposed to be implemented three years after a country ratifies the FCTC. Most of the countries in the Americas ratified between 2003 and 2006 which means that we have 22 countries that should have implemented that article at this point and we have 13 who have done so. So the thing is that since Brazil, the US, Canada and Mexico are among those 13 countries that have implemented this article, we have 86% of the population in the Americas that are covered by that mandate. But then as I think you mentioned in your article, well article 11 on packaging and labeling, putting information for consumers to know that this is a harmful product shouldn't be that difficult for a government to implement. So on one hand we are very happy, I'm proud to report that this has been the main progress on the other hand, we are like, oh, this is something, let's say basic that we as health public officials should implement in our respective countries. So let's move on to more difficult policies and also as you mentioned more effective, smoke-free environments and taxation. And there and also banning advertisement and promotion sponsorship. In the smoke-free environments, that's a second type of intervention where we've had more success or more countries implementing this. For this policy to be implemented, a country has to enact a law, banning smoking in all public places, indoor public places and workplaces. Basically what we have in the District of Columbia, for example, or in many states in the US, nine countries in our region have done so. We don't count the US because the US doesn't have a federal law, although have many states that have done so. We count Canada because all of provinces in Canada have done so. So since by sub-national laws, they are banning smoking, then we include Canada in this list. But we also have Guatemala, Panama, Colombia, Peru, Barbados, Honduras, and Trinidad, and Tobago. And I want to stop on Uruguay because Uruguay has been the, I'm going to say our little baby in terms of implementing the famous Empower policies before the Empower acronym came to existence. And Uruguay started doing this in 2006, 2005 actually with a decrease. And this was because of having, well not only because of that, but one thing that contributed to this was the fact that the president was an oncologist, the former president of Uruguay, and very interested in general, in non-communicable diseases, and in particular in tobacco control. So there was political will there. And that's how this happened in Uruguay. And my point being that there's political bill in small countries that are willing to move forward, to implement the mandates that they committed to when they ratified the FCC. But there's not necessarily enough technical assistance or financial resources to do that. And the same thing in banning advertisement, which is very difficult because this is something that the tobacco industry opposes, I would say in a greater way than in other policies. This year when Peru approved a law on health warnings and banning smoking in public places, the tobacco industry, well unofficially, or BAT in particular unofficially said that smoking environments are health warnings. Well, they would not greatly oppose but banning advertisement promotion sponsorship would be something that they would fight. So surprisingly we don't have a ban on advertisement promotion sponsorship in many countries right now. Only two countries have been able in the Americas to do so, Panama and Colombia. And of course they face a challenge to implement it. In taxation, covering the main policies not talking surveillance, but in taxation we have the recent success in Mexico that in September approved an increase in tobacco taxes of seven pesos. That's about 60 cents US dollars, which is gonna be very important. The effect is gonna be great in consumers because the pack of cigarettes the average price of a pack of cigarettes is gonna move from about two dollars to almost three dollars. So it's gonna have an impact and hopefully we're gonna be able to measure this in the coming months. So to summarize this, yes, there's political will in some countries. Some countries have made progress but the progress has been unequal. And let's say it's low in prices in general. Many of the countries that I have mentioned with the exception of Uruguay and Panama have enacted laws in the last two to three years. So yes, I think there's a momentum for tobacco control in a region as well. And the dynamic is very fast. Once the president or the president of the Health Commission at the Congress wants to move forward the legislation, the request for technical assistance is immediate. It's like we need experts to come and present to Congress members the evidence that banning smoking in public places is not gonna harm bars and restaurants. And you need to go like the next week and do that presentation. We need to present to the minister of finance the worldwide evidence that increase in tobacco taxes is gonna increase revenues and how to improve their tobacco taxation structure as to reduce consumption but at the same time increase revenues. And those are the challenges that we face on a day-to-day basis. And definitely having the umbrella of the Bloomberg Initiative has helped us work in a better way. Pajo, we are the secretariat of the ministries of health in the Americas so we'll respond to what national authorities request us but it's been great to work together with American organizations like the Campaign for Tobacco Free Kids who have the expertise on tobacco taxation and on mass communication media as to convey the message to policy makers. So that's a situation if you want me to elaborate. I can speak two days about tobacco control and the FCC but I'll stop there. Thank you Rosa, that's a very nuanced, crisp summary and a positive one really in some respects in what you're describing in terms of the momentum and progress that you've seen in some key places in recent years. But also I hear you saying that there really is an appetite for doing more. There are some clear unmet demands in which external, some sort of external support and technical and financial sources might actually deliver some quick returns. So thank you. Charles, tell us a bit more about the China context in terms of the many, oftentimes there's considerable pessimism around getting movement on tobacco control and getting the government to see it as in its best financial stability or political governing best interest to take this issue on. There's many big and harrowing projections made around the consequences of smoking in China. Tell us a bit more about how this plays itself through. First of all, I mean CSAS is a pathologically nonpartisan organization so I thought I was here to represent smokers but I guess not. Well it depends. But I guess, first of all let me congratulate Tom on an excellent paper and I expect nothing less of a fellow USTR alumnus but particularly focusing on the hypocrisy that in trade agreements with respect to continuing to negotiate on behalf of tobacco tariff reductions and even at the same time as we are very cognizant of the challenges here and are trying to move, I think is absolutely important and something that I don't think there's a whole lot of people in the healthcare community with WHO or else wise that focus on the trade impacts or trade aspects of this issue and I think knitting the two sides together is very important. I'm used to talking as a China person, this is not an area of particular expertise for me but I'm used to talking as a China person of superlatives or big numbers and the numbers with respect to smoking in China are superlative is probably the wrong word but China is the largest producer and consumer of tobacco products. About 300, between 300 and 320 million Chinese smoke that's one in three people, well smokers worldwide and of those people the most recent survey that was done I think by WHO arm suggested that only 16% of Chinese smokers are actually considering quitting. There are about one million tobacco deaths a year, that's again that's about one in four tobacco related deaths globally are Chinese that will double in the next 10 years and I think as Tom pointed out there's a shocking percentage of between a third and 40% of Chinese medical personnel who actually are smokers so when you've got six and 10 doctors and professionals that are smokers you've got a major social challenge even before you get to the question of how do you deal with people that don't know better. Since 1980 in 30 years lung cancer up 465% although as some will say perhaps that relates to a failure to diagnose back in 1980 lung cancer but even so a shocking number and then you get to I think one of the heart of the root of the problem. The China National Tobacco Monopoly does $76 billion a year in profit and taxes, $61 billion of which is taxes. This is that none of that I can assure you goes to tobacco prevention that is a major source of revenue for government that is constantly on the prowl for new tax revenue so the fact that tobacco is such an important revenue source is an enormous challenge. Meanwhile if you've got that $61 billion figure in mind the Ministry of Health calculates that only about $22.7, $23 billion are costs, medical costs related to tobacco consumption. So in China there is a perception that unlike I think some of the things that Tom was bringing up there's a perception that well the numbers are worth it. For the $61 billion you get in taxes you only have to give up $23 billion in costs. So again you have this inherent, Tom was talking about the importance of putting incentives in place to prevent tobacco use. Really the disincentives in China are right both on a social level, a revenue level and even on a health level from what they're seeing. I think one of the most damning things that can be said about China's approach to this is China did ratify the Premier Convention in 2006 and immediately turned over management of implementation of the FCTC to the same ministry that is responsible for overseeing the tobacco monopoly. So you effectively have the Fox guarding the henhouse with respect to tobacco control and with very little incentive to dramatically increase implementation. Now what's interesting recently and so for those of us that are looking for signs of optimism here, the Ministry of Health has been very vocal in its criticism not just of the structure of FCTC implementation but of the need for increased attention to tobacco control generally. So even though there is this kind of back of the envelope calculation about health costs I think there's a recognition somewhere at some point that the health costs associated with tobacco prevention and tobacco use are much higher than perhaps they talk about. If I sort of look at the three issues that are challenges and need to be overcome in China and then I'll shut up, first of all it's the housing of implementation. Clearly the Ministry of Health, if anybody should be more responsible for implementation of FCTC than the Ministry of Industry and Information Technology which doesn't make a lot of sense. I would argue probably because the Ministry of Health is frankly a fairly weak organization within the Chinese bureaucracy that there should be an effort to put this kind of implementation directly under the State Council or as perhaps under the Politburo you've got the premier, the incoming premier in 2012, the likely premier who has taken a strong interest in role in Chinese healthcare reform. That would be an appropriate person to be championed for this to the extent that he would be, he would look at this as a source of political utility. But I think that's, clearly the bureaucratic efforts to take on this challenge has not been very serious to date. With respect to the question about 23 billion versus 61 billion, I think when you get down to the numbers have to be debated. And particularly when you consider that the vast majority of Chinese don't have any healthcare at all. They are not covered by insurance, they don't seek treatment, and therefore their deaths are not counted as part of the expenditures. They don't get, because they're not getting any payments out of the state or they're not costing anything, they're dying and they're effectively a zero cost. Loss from smoking. The, as the Chinese do roll out, China does roll out more effective healthcare reform and implementation. I think you'll see that those numbers escalate quite dramatically. And particularly when you're getting to a question by 2020, when a lot of healthcare reform is supposed to have taken place, when you're getting it to two million deaths from tobacco use a year, that number is gonna be significantly higher than 61 billion dollars. And so that's the point at which the Chinese government starts to think and says, well, maybe we ought to take a more pragmatic approach to this. Finally, and I'm not sure what the right answer to this is. Beijing and the Chinese government is obsessed with social stability, obsessed with that as a matter of domestic political survival, to the extent that there is an effort by Beijing to employ bread and circuses to maintain social stability. For the 800 million, 750, 800 million rural residents, smoking is the circus. The average Chinese, average farmer or peasant out in the rural community really counts on his or her cigarette or pack or three packs in many cases. And denying that is going to be, I think, perceived at least by Beijing as a major source of political instability. The question is, can we and other middle-income countries, can we and can middle-income countries around the world take the example, appropriate examples of tobacco prevention and control and demonstrate that it doesn't necessarily result in massive instability? I think that's something that where, above and beyond the question of technical expertise, I think that's something that Beijing really does need to see over the next few years. I will say, though, having just come from Beijing and gone out to eat with some friends at a restaurant, I mentioned the fact that it was quite remarkable that everybody in the entire restaurant was smoking and that we had smoking bans in the United States. The notion that among my fellow patrons that we would actually, it's to the smoking ban in China was perceived as the most ridiculous thing possible. So got a long way to go. Thanks. Thanks, Charles. Let's come back to Tom for a moment and let's revisit this whole question of political feasibility. We've heard a lot about what is possible. You've proposed tax, surtax, G20 surtax. There's the whole question of where's the political will in the consortium that could drive such a process because it will take leaders, it will take some combination of leaders that choose to conclude that it's in their best interest to move such a thing forward. And, and we haven't really heard much here so far, about the power of industry. I mean, there is a whole counter argument that the industry, as it faced the Framework Convention coming into force, as it saw the Bloomberg and Gates and WHO initiatives come forward, as it saw certain other countries beginning to put stronger regulatory environments in place. Interest has not been passive. And it's been documented quite dramatically by analysts like John Samet and others about the muscularity and the robustness of that. So when you look at the political feasibility, you have to take into account the possibility of a strong counter reaction that would perhaps nullify or stop in the tracks those who are making a political calculation of how much of a priority should this be? Okay, yes, we know the data's there. We know the economic costs are there over the long term. We know we have an opportunity this year with the NCD summit in September of 2011 and all of the other things. We know we have a treaty. We know we have a framework. We know it works. All of those things are strong arguments, but you have to address this political feasibility and the fact that there's not a passive opponent. There's a very active and muscular. Just tell us a bit about that. How do we move your strategy forward against those questions? Sure, well thank you for that great question. I also wanna thank the rest of the panel for their very generous comments about the paper. It's nice to meet Tim and Rosa in person and share a stage with you. It's always nice to see Charles. I'm actually reminded that Charles was the person who introduced me to Steve, so in a way is to blame for all of this. So political will. Tobacco, well I think you certainly need it on taxation for any social goal as I've suggested before, there has been a extreme willingness. It's not a question of raising tobacco taxes in my view. I think there's been a lot of willingness in many countries, particularly in high income countries to do that. The real challenge is the one that Tim mentioned is getting them to use a portion of that to actually spend it on international tobacco control. And I think there's two ways to do that. The first obviously is leadership. When you think about other contexts in which taxation has been employed as a funding device for global health aims, you think of President Chirac around unit aid and the personal leadership it took to institute a taxation, actually in that case an entirely unrelated service to use that resources. And it only garnered in that case about seven countries. I've been told by other US government high level officials not at the CDC, one of the real challenges is that tobacco is not on the radar in global health discussions throughout much of the US government and that has to change. And encouraged by the opportunity to do this paper in this event because I think that these are the kinds of things in the lead up to the 2011 summit that have to push that forward to try to generate that leadership. That's what I think you need to see. So that's the first component is real political leadership. Second is there's actually history for, I think it's Australia, but I'm sure somebody here will correct me, the tying tobacco taxes to things that the domestic country wants as an explicit bargain so to speak for imposing higher taxes. So I think it's Australia that was able to do this quite successfully, which is ex ante say what they will use the rest of the taxes for domestically to build support for it and then that they will also do it for this. So I think that type of strategy may make sense in this context as well. I also think on the political side that it doesn't need to be recognized that you need differential strategies. I think the CODA approach as I mentioned in the paper I think makes a lot of sense for low income countries where you do not have this level of a tobacco epidemic yet. That it will be persuaded for the types of awards that you could provide through that type of incentive mechanism. It is not a solution for China. You are not gonna be able to mobilize the kind of funds you would need to really alter what's happening in that situation through any incentive or prize mechanism. Maybe it could work on a sub national level, I don't know, but it certainly is not going to function on a national level. But I do think preventing expansion of the tobacco epidemic in Africa with women I think is important because if it takes hold there you're really looking at a substantial increase even on those numbers that I put forward. Great, thank you very much. Let's open to the floor for some comments and questions. We have microphones. So let's take three, a round of three quick comments and questions. Please just put your hand up or stand up and identify yourself and we'll take three and then we'll come back to our speakers. If you wish to direct your question or comment to a specific person here on the round table please feel free to do that. It's late Friday afternoon, Steve. Right here. You wowed the troll. Jerome Pichella from the Canadian Embassy. Please speak up a bit. Yeah, it's on. Okay, so Jerome Pichella from the Canadian Embassy just a very small thing. When you mentioned Australia possibly, in Canada that's what's been done. So taxes on cigarettes on the provincial level are usually explained, usually it's explained to the public what they're gonna be used for. For instance, in Quebec where I come from everybody knows that smokers have paid for specific programs, shall we say. It's usually something that's not so popular with the smokers but popular with everybody else. That's it. And those monies are put towards dedicated tasks. Other comments or questions? All right, let me come back then to our speakers and ask them about what they think the value could be of moving towards this summit next September. There's an alliance forming, there's three or four other key focal areas where attention could be dedicated but when you look at tobacco, you have this existing framework, you have a consensus, you have mobilized interests. You would think that it would be a win, that this would be a big moment to sort of move the debate forward significant. Do you feel that that is true and if so, how would you begin to frame out the approach to get the best outcome next September? Tim, do you have a... Well, in some ways this might be a small piece of it but I was actually thinking as Rosa was talking about the needs in the Americas for technical assistance and I had sort of been saying, well gee, we have all this technical assistance expertise that we're not really basically bringing to bear because we sort of had the resources but we don't have the mandate, the fiscal mandate to do it. So it's whether in some ways a kind of crisp drill down around what a technical assistance program that was really global, but both probably country, regional and global in nature would really look like and I think this is something where, WHO could also play a good coordinating role as well as the regional organizations like PAHO. What do you need? If you had XYZ, how would it help move forward and then how could we create structures and infrastructures given both the existing national and international organizations that house the expertise but also house the delivery capability for that? How could we do it? Where could we get the money? I think that would be, make people really understand the gap and that there really is some very practical things that could be done that would dramatically- So scoping out the gap, the unmet demand with much greater granularity in going towards the summit is one big win that you would imagine. Rosa, what do you- Well, yes, but before, I was thinking of the opportunity that the summit tried to write us to convey once again the term set to put it in the radar because what you mentioned for the US, it's also the situation for many countries in our region. It's just that tobacco is not there in the public agenda. And so once most of the time, by chance, you have the attention of high level congress members or national authorities from sectors other than health, which are already greens, then it's like when suddenly, yes, we can increase taxes. I mean, that's not difficult. Or yes, we can draft this, prepare this bill and put it for discussion. So for us, the summit is this opportunity to put tobacco control as one risk factor and one main risk factor in the non-communicable diseases epidemic there in the radar. And in terms of what technical assistance we need, yes, I think we definitely have now after five years of working in trying to implement the FCC. Because the first between 2003 and 2005 was mostly communicating what the FCC is and the importance of ratifying it. And in 2005, 2006, we moved towards implementing it. I think now it has pretty much no idea what specific needs needed after having been presenting evidence at, I don't know, five or six different congresses in the country. And what about political leadership? I mean, one of the uncertainties around the summit next September is which heads of state or which prominent global opinion figures are gonna show up to make the case? I mean, when you look back at the UN special session on HIVA, it's a decade back, it's sort of seen as a groundbreaking moment and one that turned global opinion and turned opinion in key states. It's pretty powerful global personalities showing up and making the case. Who's gonna lead the way on tobacco at this point, do you think? Or who might be enlisted to sort of play that leadership role? I mean, I think you can, I think you're right, Tim and Rosa, that scoping the unmet demand and bringing it across and making it clear as to that this is feasible and affordable and these things can be done and trying to set the bar in terms of the next five years could achieve these things or the next set some concrete parameters and objectives. That would be significant progress but there needs to be some kind of political leadership breakthrough that we haven't seen and Gro Bruntland drove that FCTC and it's been in force now for several years and I think much of the uncertainty around it today is a money-based but it's a political will-based uncertainty so we need to address that as well, I'm looking forward. Do you, Charles, any thoughts? Well, it would be useful if the political leaders didn't smoke, that would be a good start. But we won't name names. I think you're absolutely right though. I mean, it requires more than numbers, both economic numbers and health numbers. It requires a small number of individuals who have authority and power to do something who grasp what this is and see it as an opportunity for them to make a mark on the world and then to do it. And so maybe that's for those of us who may not actually be in that position ourselves but that one of the things that we should set as our task between now and then is trying to see if we can actually make the case to people both of the opportunity here but also the personal opportunity that somebody may have to really make a difference because that is one of the things that is, you can say about this, that tobacco epidemic is, it is something where there's a leadership gap. And so it does provide an opportunity, it's tremendously challenging to do something partly because of that, but it also is a tremendous opportunity for an individual or smaller individuals to make a real difference. Yes, Tom? Well, I think that Charles's point earlier about the view of hypocrisy around US trade policy with what we're doing domestically on tobacco control actually plays out also in the global health context of what we're doing domestically being so different from what we're doing internationally and what the potential is there. So I think that it's incumbent on the people that work full-time in these areas to make that case in a way that is clear because I think for, it's not just the US or other developed countries as well but a number of countries have expressed a strong interest in pursuing global health for reasons talked about in the presentation there. And I think it's really making it clear about the potential in this case for relatively low amounts of investment making and enormous amount of difference is significant. So I think it's in part making that case in advance. I mean, part of it might also be that you have, you have a framework emerging for this summit. You have leadership coming out of CARICOM and Sir George Alain and Jamaica and Luxembourg charged. And the Secretary General's at some point is ultimately carrying some responsibility and there's still time. There's still time to think through how do you put the burden of delivering leaders from low and middle income countries in particular as well as from the wealthy countries? If this is seen as something that is carried overwhelmingly by wealthy countries, by the United States and Canada, it's not gonna go very far. I just don't think it's gonna go very far. If it's seen as lecturing the emerging powers dominating the G20, it's not gonna go very far. So there's gotta be a game plan and I think it's a game plan that has to be one that extends well beyond next September. It's gotta be a game plan that sees that as an important sort of step. Charles, I know we're getting at five and we have some daycare issues, so do you have any, if maybe we should take one last round of comments and then we can close. So Charles, would you like to offer, talk just a quick bit on illicit trafficking. I mean, I think one of the things that back during my USTR days that when we were looking at things to focus on with respect to intellectual property rights challenges that coming out of China, and we looked at what pirate and counterfeit goods are coming from China into the United States. The overwhelming number of dollar value of goods coming from China that was pirated were essentially cigarettes. Tobacco products coming from China represented well over 50% of the total seizures of traffic to goods in intellectual property. That doesn't mean necessarily that these were fake, that there was a sawdust in these cigarettes. That just means that these were perhaps US branded product that was produced overseas coming into the state. So there is a huge challenge there. And those products that come in remember are not subject to the same kind of tax regime that is in place. And so none of that goes to prevention and control. So it's a major challenge and customs does their best, but to be candid, these are not seen as the highest order of priority from customs to seize these kind of illicit traffic in tobacco goods. Rosa, does this issue figure in PAHO's strategy? Yes. Yes, well definitely, I'm coming back to your question about the leaders. Well, one of, I mean, the group of Mercosur, the countries in the southern cone have been very proactive in terms of discussing the illicit trade impact on public health and also on economic issues. So it is a public health problem for us. It is though, I mean, I have to say, located in certain areas in the southern cone, there's mostly counterfeit cigarettes coming from one country to the other three. And then a bit in the Caribbean. And in Central America, no, not much. I mean, the Indian area, I mean Peru, Colombia, and Ecuador, there is some, but nothing apparently. Or so far, we haven't identified a big source that make it Paraguay. So yes, this is an issue, and I hope that looking towards the U.N. summit in September, the community income countries in our region that have been leaders in tobacco control, might, I hope they take also this as an opportunity to be leaders in this summit as well. Thank you. Tim, would you like to offer any closing comments? Well, maybe my last comment would just be that we keep in mind this idea that we've been struck with, that the thing about tobacco is it's a winnable battle. And it's something where we do have the capacity with governmental activity, non-governmental activity, private sector activity in the world to keep Africa from going down the devastating path that we've gone through. We have middle income countries that have the internal capacity to, as many of them are, grasp hold of their destiny, and some of them aren't, of grasping hold of their destiny, and stopping this epidemic in its tracks, and then reversing it. And we, certainly within the United States, we have the capacity to turn tobacco use into a minor public health nuisance with all the tools that we have at hand and a little creative ingenuity over the next five to 10 years in focus. We can turn it into a minor public health nuisance. There's no reason why we have to be struggling like this 50 years from now, or have a billion deaths, but to have our great-grandchildren look back on the 21st century and say, what were we thinking that we let a billion people die for this ridiculous reason? Makes no sense. Thank you. Tom, congratulations on a really fine paper. We're very proud to be associated with it. You get the last word this afternoon. Well, thank you for that, and thank you again for the opportunity to do the paper and for this event today and all of you coming. I do think there is leadership to be tapped out there. I'm reminded, I was thinking that a lot of what is going to move tobacco forward is going to be holding people to commitments that they've already made. The convention is one of the most widely subscribed treaties in the world. The thinking of yet another USTR alumnus that I'm not sure if it's World Bank President or Ambassador Zellick now, but is actually on record supporting with former Prime Minister Gordon Brown this type of taxation on tobacco to fund this purpose. There are institutions and leaders out there, and I think it's incumbent on all of us to make the case for them to give them the room to operate on this important issue. Thank you, Tom. And I just want to repeat my, on behalf of everyone here, our thanks to all of you for being with us this afternoon and for Tim and Kirsten for coming from Atlanta to be with us. So, please join me. I hope I didn't keep you for too long. My ex-wife's keeping me. Either of you. No.