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69San Francisco created another notable ex-ample of a government program aimed atreducing disparities by making health careservices accessible and affordable for unin-sured residents. Although it does not provideFRAMING HEALTH MATTERSS76|Framing Health Matters|Peer Reviewed|Koh et al.American Journal of Public Health|Supplement 1, 2010, Vol 100, No. S1
health insurance, the Healthy San Franciscoinitiative offers universal access to primaryand preventive care to uninsured residentsthrough a clinic network with a sliding-feescale.70Tobacco DependenceWith 5 million preventable deaths world-wide attributed to tobacco use each year,tobacco control deserves our highest commit-ment. The tobacco industry has profited overmany decades from its comprehensive mar-keting efforts targeting youths, lower-SEP pop-ulations, minorities, and developing countries,thereby creating broad societal and global in-equities.71The burden of tobacco addiction and to-bacco-related deaths falls heavily on develop-ing nations especially. Worldwide, 1 billionmen smoke; 50% of men living in developingcountries compared with 35% of men living indeveloped countries are among them.68,69China, where nearly 70% of men smoke,consumes more than 30% of the world’scigarettes.72,73To counter this global public health chal-lenge, the WHO launched the FrameworkConvention on Tobacco Control, the first andonly international public health treaty. To date,166 countries have both signed and ratifiedthis treaty, committing their governments toadopting a comprehensive range of measuresto combat the health and economic effects oftobacco.74The United States, along with only 25other countries, has not signed and ratified thetreaty.74If implemented aggressively, the treatyarticles should address worldwide tobacco dis-parities. As the first effort of its kind, however, thetreaty faces challenges in implementation in thediverse political climates throughout the world,with their competing economic incentives andpriorities and their resource scarcities. It isimperative that those involved in implemen-tation of this historic international agreementtake the issue of disparities into explicit con-sideration.Previous analyses of data from the GlobalYouth Tobacco Survey (of children aged13–15 years in developing countries) showedthat more than 75% of youths support smoke-free policies despite reports from the majoritythat they are exposed to smoke in publicplaces.75Further attention to reducing globaldisparities in tobacco use and its consequencesshould focus on establishing smoke-free policiesin public places to protect children and toestablish smoke-free norms for the next genera-tion.In the United States, effective statewideprevention and cessation programs, startingwith those created in California and Massa-chusetts, have used a comprehensive socialdeterminants approach that integrates mediacampaigns, policies, price increases, and othertactics to aid communities, schools, families,and individuals.