Exceeding WHO Framework Convention on Tobacco Control (FCTC) Obligations: Nepal Overcoming Tobacco Industry Interference to Enact a Comprehensive Tobacco Control Policy

Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh

BACKGROUND

In Bangladesh, the 2013 Amendment of the Tobacco Control Act made graphic health warnings (GHWs) on the upper 50% of all tobacco packs obligatory. However, at the time of writing (May 2022), GHWs are still being printed on the lower 50% of packs. This paper seeks to explore how the tobacco industry undermined the development and implementation of GHWs in Bangladesh, a country known for a high level of tobacco industry interference (TII) that has rarely been examined in the peer-reviewed literature.

METHODS

Analysis of print and electronic media articles and documents.

RESULTS

Cigarette companies actively opposed GHWs, while bidi companies did not. The primary strategy used to influence the formulation and delay the implementation of GHWs was direct lobbying by the Bangladesh Cigarette Manufacturers' Association and British American Tobacco Bangladesh. Their arguments stressed the economic benefits of tobacco to Bangladesh and sought to create confusion about the impact of GHWs, for example, claiming that GHWs would obscure tax banderols, thus threatening revenue collection. They also claimed technical barriers to implementation-that new machinery would be needed-leading to delays. Tensions between government bodies were identified, one of which (National Board of Revenue)-seemingly close to cigarette companies and representing their arguments-sought to influence others to adopt industry-preferred positions. Finally, although tobacco control advocates were partially successful in counteracting TII, one self-proclaimed tobacco control group, whose nature remains unclear, threatened the otherwise united approach.

CONCLUSIONS

The strategies cigarette companies used closely resemble key techniques from the well-evidenced tobacco industry playbook. The study underlines the importance of continuing monitoring and investigations into industry conduct and suspicious actors. Prioritising the implementation of WHO Framework Convention on Tobacco Control Article 5.3 is crucial for advancing tobacco control, particularly in places like Bangladesh, where close government-industry links exist.

Tobacco Control in Denmark: How the Ugly Duckling Turned into a Swan

INTRODUCTION

The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, a point-of-sale display ban, a ban on characterizing flavors (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all-schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019.

AIMS AND METHODS

Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research center. We used the nominal group technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan.

RESULTS

The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda-not a political one, and effective professional campaigns.

CONCLUSIONS

Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda.

IMPLICATIONS

In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda-not a political one, and effective professional campaigns. This is consistent with findings from other countries.

How can advocates leverage power to advance comprehensive regulation on ultra-processed foods? learning from advocate experience in Argentina

BACKGROUND

The use of corporate power to undermine public health policy processes is increasingly well understood; however, relatively little scholarship examines how advocates can leverage power to promote the successful adoption of public health policies. The objective of this paper is to explore how advocates leveraged three forms of power - structural, instrumental and discursive - to promote the passage of the Promotion of Healthy Eating Law (Ley 27,642) in Argentina, one of the most comprehensive policies to introduce mandatory front-of-package (FOP) warning labels and regulate the marketing and sales of ultra-processed foods (UPFs) adopted to date.

METHODS

We conducted seventeen semi-structured interviews with advocates from different sectors, including civil society, international agencies, and government. Both data collection and analysis were guided by Milsom's conceptual framework for analyzing power in public health policymaking, and the data was analyzed using hybrid deductive and inductive thematic analysis.

RESULTS

Advocates harnessed structural power through the leveraging of revolving doors, informal alliances, and formal coalitions, enabling them to convene discussion spaces with decision-makers, make strategic use of limited resources, and cultivate the diverse expertise (e.g., research, nutrition science, advocacy, law, political science, activism and communications) needed to support the law through different phases of the policy process. Advocates wielded instrumental power by amassing an armada of localized evidence to promote robust policy design, building technical literacy amongst themselves and decision-makers, and exposing conflicts of interest to harness public pressure. Advocates exercised discursive power by adopting a rights-based discourse, including of children and adolescents and of consumers to transparent information, which enabled advocates to foster a favorable perception of the law amongst both decision-makers and the public. Key contextual enablers include a political window of opportunity, the COVID-19 pandemic, and the ability to learn from the regional precedent of similar policies.

CONCLUSIONS

Public health policymaking, particularly when encroaching upon corporate interests, is characterized by stark imbalances of power that hinder policy decisions. The strategies identified in the case of Argentina provide important insights as to how advocates might harness and exercise structural, instrumental, and discursive power to counter corporate influence and promote the successful adoption of comprehensive UPF regulation.

The Perfect Storm: Applying the Multiple Streams Framework to Understand the Adoption of a WHO Framework Convention on Tobacco Control-Based Policy in Mexico

BACKGROUND

The aim of this study was to document how Mexico adopted a WHO Framework Convention on Tobacco Control (FCTC)-based national tobacco control law.

METHODS

We analyzed publicly available documents and interviewed 14 key stakeholders. We applied the Multiple Streams Framework (MSF) to analyze these findings.

RESULTS

Previous attempts to approve comprehensive FCTC-based initiatives failed due to a lack of political will, the tobacco industry's close connections to policymakers, and a lack of health advocacy coordination. Applying the MSF reveals increased attention towards collecting and sharing data to frame the severity of the problem (problem stream). The expansion of a coordinated health advocacy coalition and activities led to increased support for desired FCTC policy solutions (policy stream). The election of President López Obrador and legislative changes led to a deep renewed focus on tobacco control (politics stream). These three streams converged to create a policy window to secure a strong FCTC-based initiative on the political agenda that was ultimately passed.

CONCLUSIONS

The Mexican experience illustrates the importance of continued health advocacy and political will in adopting FCTC-based policies. Other countries should follow Mexico's lead by collecting and sharing data through coordinating efforts in order to be prepared to seize political opportunity windows when strong political will is present.

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Asian, regional, and national burdens of respiratory tract cancers and associated risk factors from 1990 to 2019: A systematic analysis for the global burden of disease study 2019

Background

Respiratory cancer is the leading cause of cancer-related deaths worldwide, but its statistics vary between the East and West. This study aimed to estimate the burdens of tracheal, bronchus, and lung (TBL) cancer and larynx cancer and their attributable risks from 1990 to 2019 in Asia, and at regional and national levels.

Methods

This research evaluated the incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) for respiratory tract cancers using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 database. Age-standardized rates were calculated for TBL cancer from 1990 to 2019, adjusted for smoking and socio-demographic index (SDI). Deaths from TBL cancer and larynx cancer attributable to each risk factor were estimated for 33 Asian countries.

Results

The age-standardized incidence and death rates for TBL cancer in Asia declined from 2010 to 2019, while the incidence rate of larynx cancer increased. Smoking was the leading specific risk factor for deaths from both TBL and larynx cancers. The burden of TBL cancer in Asian countries was influenced by SDI and smoking, particularly among males in Central Asia. Deaths, DALYs, and incidences of larynx cancer in East Asia had not changed significantly over the past 30 years, but showed slight downward trends in males and both sexes combined, and an upward trend in females in recent years.

Conclusions

The past decade saw increases in numbers of incident cases and deaths from TBL cancer and larynx cancer in Asia. SDI and smoking were the main factors influencing the disease burden of TBL cancer in Asian countries. This study highlights the need for tailored cancer control programs to address the burden of respiratory tract cancers in different Asian countries.

A framework of NGO inside and outside strategies in the commercial determinants of health: findings from a narrative review

BACKGROUND

Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health.

METHODS

We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice.

RESULTS

One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative.

CONCLUSION

The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries

OBJECTIVE

To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico.

DESIGN

Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022).

RESULTS

In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing.

CONCLUSION

Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Advocacy counterstrategies to tobacco industry interference in policymaking: a scoping review of peer-reviewed literature

BACKGROUND

There has been remarkable tobacco control progress in many places around the globe. Tobacco industry interference (TII) has been identified as the most significant barrier to further implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Civil society has been recognised as a key actor in countering TII. While TII has been extensively studied for several decades now, there is little research that focuses on counteractions to limit it and their effectiveness to do so. This scoping review seeks to map the peer-reviewed literature on civil society's activities of countering TII in policymaking to identify common counterstrategies and assess their effectiveness.

METHODS

Data sources: We searched Embase, IBSS, JSTOR, PubMed, Science Direct, Scopus and Web of Science using the following terms: ("Tobacco industry" OR "Tobacco compan*") AND. ("corporate political activity" OR "CPA" OR "lobbying" OR "interference") AND ("advoca*" OR "counter*" OR "activi*"), without time or language restrictions.

STUDY SELECTION

Our selection criteria included peer-reviewed studies that were written in English, German, or Spanish that drew on primary data and/or legal and policy documents and reported at least one specific example of civil society members or organisations countering tobacco industry action-based strategies.

DATA EXTRACTION

Advocates' counterstrategies were analysed inductively and countered industry strategies were analysed using the Policy Dystopia Model (PDM). Perceptions of effectiveness of countering attempts were analysed descriptively.

RESULTS

We found five common counterstrategies among 30 included papers covering five WHO regions; 1. Exposing industry conduct and false claims; 2. Accessing decision-makers; 3. Generating and using evidence; 4. Filing a complaint or taking legal action; 5. Mobilising coalition and potential supporters. These counterstrategies were used to work against a wide range of industry strategies, which are captured by five action-based strategies described in the PDM (Coalition Management, Information Management, Direct Access and Influence, Litigation, Reputation Management). While some studies reported the outcome of the countering activities, their impact remained largely underexplored.

CONCLUSION

The review shows that peer-reviewed literature documenting how civil society actors counter TII is scarce. It suggests that advocates employ a range of strategies to counter TII in its different forms and use them flexibly. More work is needed to better understand the effects of their actions. This could stimulate discussions about, and facilitate learning from, past experiences and help to further enhance advocates' capacity.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh

OBJECTIVES

This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs).

METHODS

We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections.

RESULTS

Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies.

CONCLUSION

This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

'To be honest, I'm really scared': perceptions and experiences of intimidation in the LMIC-based tobacco control community

BACKGROUND

It is well-evidenced that environmental or human rights advocacy comes with risks for those involved. Much less is known about the risks of tobacco control advocacy despite the emphasis on tobacco industry conduct. This study explores the experiences and perceptions of intimidation among members of the tobacco control community in low- and middle-income countries (LMICs).

METHODS

We interviewed six experts representing each of the World Health Organization (WHO) regions to inform an online survey conducted among the LMIC-based tobacco control community. Thematic analysis was used for analysing qualitative data while quantitative data were analysed descriptively.

RESULTS

Twenty-three participants from five WHO regions completed the survey. Almost three-quarters of survey participants reported that they, or another member of the tobacco control community in their country, had experienced intimidation. The most frequently reported forms of intimidation were discreditation on social or traditional media, legal threats/action and threatening messages. Physical intimidation, theft/burglary, cyberattacks and surveillance were individually rare but reported collectively by over 40% of participants. Results suggested intimidation might be increasing and changing in nature, and undermines tobacco control efforts: it affects organisations' capacity and agenda, their ability to build relationships with those needed to advance policy, as well as the well-being of individuals. Participants used a range of strategies in response to intimidation and reported that they would benefit from better support.

CONCLUSION

This exploratory study suggests that intimidation is a crucial challenge for the tobacco control community. There are several measures the global tobacco control community could take, including establishing an international support mechanism and building capacity to deal with intimidation and draw attention to it.

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City

Background

Smoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places.

Objectives

This study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal.

Methods

A cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place.

Results

The overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of ‘no smoking’ notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the ‘no smoking’ notices displayed fully adhered to the contents as prescribed by the law.

Conclusion

As more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the ‘no smoking’ notices needs close attention to adhere to the legal requirements.

Prevalence and trends in tobacco use, secondhand smoke exposure at home and household solid fuel use among women in 57 low- and middle-income countries, 2000-2018

BACKGROUND

Tobacco use, secondhand smoke (SHS) exposure and household solid fuel use in women of reproductive age can cause morbidity and mortality for both women and offspring.

OBJECTIVES

We aimed to determine the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women in low- and middle-income countries (LMICs) and their secular trends between 2000 and 2018.

METHODS

We used the most recent data from the Demographic and Health Surveys in 57 LMICs (n = 1,598,111) that were completed between 2010 and 2018 to assess the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women of reproductive age (15-49 years). We also used data from 41 selected LMICs that had data from two or more surveys completed between 2000 and 2018 to assess secular trends in the prevalence of tobacco use and household solid fuel use among women.

RESULTS

In 2010-2018, the overall prevalence of tobacco use, daily SHS exposure at home and household solid fuel use among women in 57 LMICs was 3.2% (95 %CI = 3.1-3.3), 23.0% (22.8-23.2), and 65.6% (65.3-65.9), respectively. The prevalence of tobacco use was lower among pregnant women than non-pregnant women (2.1% vs. 3.3%), but the prevalence of daily SHS exposure at home (24.4% vs. 22.8%) and household solid fuel use (69.1% vs. 65.3%) was higher among pregnant women than non-pregnant women. About 16% of the women presented two or three simultaneous risk factors. Between 2000 and 2018, the prevalence of tobacco use decreased in 24 (64.9%) of 37 countries, and the prevalence of household solid fuel use decreased in 20 (50.0%) of 40 countries.

CONCLUSIONS

Tobacco use among women was much low in LMICs, but SHS exposure at home was more common. Although the prevalence of household solid fuel use decreased over time in most LMICs, these recent estimates remained unacceptably high.

Tobacco Control In Bolivia: Transnational Civil Society Efforts In Securing A Comprehensive Law

OBJECTIVE

To document the adoption of a comprehensive tobacco control law in Bolivia, a low-income country in South America.

METHODS

Analysis of the Bolivian case study by reviewing news sources, tobacco control legislation, industry websites, and advocacy reports. Application of the Policy Dystopia Model to analyze tobacco industry and health advocacy arguments and action-based strategies.

RESULTS

For decades tobacco control progress in Bolivia remained relatively stagnant due to industry interference. In the 2000s and 2010s Bolivia ratified the WHO Framework Convention on Tobacco Control (FCTC) and implemented a couple of laws that began restricting smoking in public places and tobacco advertising. In 2015, tobacco control civil society emerged with the creation of FIC Bolivia, which began coordinating efforts to counter industry interference. Between 2016 and 2020 FIC Bolivia with financial and technical support from international health groups proactively coordinated inter-ministerial meetings, identified and met with key policymakers, and held public educational socialization events to introduce and support a FCTC-based tobacco control bill. Tobacco companies argued to policymakers and the media the bill would result in lost sales/jobs, increase illicit trade and help smugglers profit but only secured minimal changes. In February 2020, Bolivia passed Law 1280, which established 100% smoke-free environments, banned tobacco advertising (except at the point-of-sale), required 60% pictorial health warnings, among others.

CONCLUSION

International financial and technical support combined with proactive advocacy strategies, including identifying and engaging key policymakers, coordinating inter-ministerial meetings, and educating the public can help pass strong tobacco control laws, especially in low-income countries.

IMPLICATIONS

Low and middle-income countries struggle to adopt comprehensive tobacco control legislation due to weak state capacity, limited resources and aggressive tobacco industry interference. This is one of a handful of studies to examine the adoption of a comprehensive tobacco control law in a low-income country, Bolivia. Proactive health advocacy strategies, including identifying and engaging key political allies, helping coordinate inter-ministerial meetings, and aggressively educating and engaging the public can help pass strong tobacco control laws, especially in low-income countries.

Evidence on article 5.3 of FCTC (tobacco industry interference in tobacco control activities) in India- a qualitative scoping study

BACKGROUND

The Tobacco Industry (henceforth TI) yearns to portray itself as being "socially responsible" and fights for the decision-making positions; that are it used to deter, delay or dilute tobacco control measures. There is little documented evidence of Tobacco Industry Interference (henceforth TII) from India, the scope of their interference and challenges faced by the experts for effective tobacco control. This research study seeks to cover this significant gap in the literature on the TI of India.

METHODS

A cross-sectional qualitative research design, based upon in-depth interviews (N = 26), was used to explore the key stakeholders' opinions regarding TII in India. The interviews used a set of questions to collect information about the participant's roles and responsibilities in tobacco control, the nature of TII faced by the participants, means of influence by TI, barriers and challenges to tobacco control efforts.

RESULTS

Most of the respondents were engaged in tobacco control, training, advocacy and awareness generation activities for 5-10 years or more. The respondents defined the TI and its scope as per their experience with the help of the power ranking methodology. Most of them perceived TI as 'manufacturers' while others consider them as 'advertisers', 'public relation companies', 'wholesalers', 'vendors', and 'Government firms with TI stocks. The research team identified six significant domains: influencing the policy and administrative decisions, Interference in the implementation of tobacco control laws and activities, false propaganda and hiding the truth, manipulating front action groups (FAG), rampant tobacco advertising and promotion activities and others under which TII activities were classified. Most respondents believed that TI players were interfering in the policy decisions, implementing the tobacco control laws and activities and manipulating the FAG. A detailed taxonomic classification of the TII strategies that emerged from our analysis was linked to article 5.3 of FCTC.

CONCLUSIONS

The study documented a significant level of TII in different domains, with stakeholders acting at various hierarchical levels. Thus providing insight into the tactics of the TI in order to enable stakeholders to anticipate and pre-empt the kinds of alliances the TI may attempt to build; stimulating academicians and researchers to undertake in-depth analysis into various strategies and therefore underscoring the need to ensuring transparency in official interaction with the TI and its representatives.

Developing more detailed taxonomies of tobacco industry political activity in low-income and middle-income countries: qualitative evidence from eight countries

INTRODUCTION

Historical evidence, predominantly from high-income countries (HICs), shows that the tobacco industry uses a recurring set of arguments and techniques when opposing tobacco control policies. This data formed the basis of a model of tobacco industry political activity known as the policy dystopia model (PDM). The PDM has been widely used in tobacco control research and advocacy and has subsequently been shown relevant to other unhealthy commodities industries in both HICs and low-income and middle-income countries (LMICs). Before it can be validated as a generic tool for researching corporate influence on policy, one needs to determine whether the PDM successfully captures contemporary corporate political activities in LMICs.

METHOD

We conducted semistructured interviews with 22 LMIC-based advocates and used the transcripts as the primary data source. The discursive and instrumental taxonomies constituting the PDM served as the starting point for the coding framework. Using thematic analysis, we combined deductive and inductive coding to ensure we captured all strategies from the PDM and the interviews.

RESULTS

This study found that the tobacco industry uses a set of discursive and instrumental strategies that is largely consistent across LMICs and with the PDM. We identified several minor contextual nuances absent from the PDM. Some of these nuances were characteristic to individual countries, while others to LMICs more broadly. They included the argument that tobacco control policies unfairly punish reputable tobacco industry actors, and an emphasis on instrumental strategies centred around maintaining a good image, rather than rehabilitating a tarnished image as emphasised in the PDM.

CONCLUSIONS

Allowing for the nuances identified in this study, the PDM has been found to be fit for purpose. The revised model should now be tested through in-depth LMIC case studies and could be used to facilitate comparative studies of unhealthy commodity industries' political activities.

Defending Comprehensive Tobacco Control Policy Implementation in Nepal From Tobacco Industry Interference (2011-2018)

INTRODUCTION

Nepal passed a comprehensive tobacco control law in 2011. Tobacco control advocates successfully countered tobacco industry (TI) interference to force implementation of law.

AIMS AND METHODS

Policy documents, news stories, and key informant interviews were triangulated and interpreted using the Policy Dystopia Model (PDM).

RESULTS

The TI tried to block and weaken the law after Parliament passed it. Tobacco control advocates used litigation to force implementation of the law while the TI used litigation in an effort to block implementation. The TI argued that tobacco was socially and economically important, and used front groups to weaken the law. Tobacco control advocates mobilized the media, launched public awareness campaigns, educated the legislature, utilized lawsuits, and monitored TI activities to successfully counter TI opposition.

CONCLUSIONS

Both tobacco control advocates and the industry used the discursive and instrumental strategies described in the PDM. The model was helpful for understanding TI activities in Nepal and could be applied to other low- and middle-income countries. Civil society, with the help of international health groups, should continue to track TI interference and learn the lessons from other countries to proactively to counter it.

IMPLICATIONS

The PDM provides an effective framework to understand battles over implementation of a strong tobacco control law in Nepal, a low- and middle-income country. The TI applied discursive and instrumental strategies in Nepal in its efforts to weaken and delay the implementation of the law at every stage of implementation. It is important to continuously monitor TI activities and learn lessons from other countries, as the industry often employ the same strategies globally. Tobacco control advocates utilized domestic litigation, media advocacy, and engaged with legislators, politicians, and other stakeholders to implement a strong tobacco control law. Other low- and middle-income countries can adapt these lessons from Nepal to achieve effective implementation of their laws.

The Application of Philip Morris' Litigation Prevention Program in South Korea

This article is aimed to identify the strategies of Philip Morris (PM, before its spin-off in 2003) and its affiliates in the intervention and prevention of tobacco litigation in South Korea. We analyzed 193 documents obtained from the Truth Tobacco Industry Documents. We found that PM organized and operated the "Litigation Prevention Program (LPP)" to create legal environments making tobacco litigation difficult to initiate and legal networks with local lawyers, media, and even competitors to effectively respond to such litigations. PM developed the LPP based on its legal strategies in the United States against tobacco litigation and disseminated them all around the world including South Korea. In 1999, the first joint action against Korea Tobacco and Ginseng Corporate (KTGC, today known as KT&G), a state-owned tobacco company, began. KTGC asked PM to support their litigation, and PM provided its legal strategies, such as sources to counter the plaintiffs' arguments, through the LPP to KTGC. In front of legal threats, tobacco companies, competitors in markets, jointly fought back the litigation in Korea. Any litigation against a single local tobacco company may confront legal networks of tobacco companies. As a result, no litigation against tobacco companies in South Korea has been able to win over tobacco companies. International legal support including the development of guidelines of Article 19 of the Framework Convention on Tobacco Control is vital for an effective legal fight against tobacco companies around the world.

Needs of LMIC-based tobacco control advocates to counter tobacco industry policy interference: insights from semi-structured interviews

INTRODUCTION

Advocacy is vital for advancing tobacco control and there has been considerable investment in this area. While much is known about tobacco industry interference (TII), there is little research on advocates' efforts in countering TII and what they need to succeed. We sought to examine this and focused on low- and middle-income countries (LMICs) where adoption and implementation of the Framework Convention on Tobacco Control (FCTC) tend to remain slower and weaker.

METHOD

We interviewed 22 advocates from eight LMICs with recent progress in a tobacco control policy. We explored participants' experiences in countering TII, including the activities they undertake, challenges they encounter and how their efforts could be enhanced. We used Qualitative Description to analyse transcripts and validated findings through participant feedback.

RESULTS

We identified four main areas of countering activities: (1) generating and compiling data and evidence, (2) accessing policymakers and restricting industry access, (3) working with media and (4) engaging in a national coalition. Each area was linked to challenges, including (1) lack of data, (2) no/weak implementation of FCTC Article 5.3, (3) industry ties with media professionals and (4) advocates' limited capacity. To address these challenges, participants suggested initiatives, including access to country-specific data, building advocates' skills in compiling and using such data in research and monitoring, and in coalition development; others aiming at training journalists to question and investigate TII; and finally, diverse interventions intended to advance a whole-of-government approach to tobacco control. Structural changes to tobacco control funding and coordination were suggested to facilitate the proposed measures.

CONCLUSION

This research highlights that following years of investment in tobacco control in LMICs, there is growing confidence in addressing TII. We identify straightforward initiatives that could strengthen such efforts. This research also underscores that more structural changes to enhance tobacco control capacity building should be considered.

Influence of Tobacco Marketing on Nepalese Adolescents: Cigarette Use and Susceptibility to Cigarette Use

Background:

Tobacco advertising, promotion, and sponsorship (TAPS) are common tactics of the tobacco industry to encourage adolescents to use tobacco products.

Objective:

The objective of the study is to assess the influence of TAPS on cigarette use and susceptibility to cigarette use among Nepalese adolescents.

Materials and Methods:

Data (n=2,878) were drawn from the Global Youth Tobacco Survey for Nepal (GYTS, 2011). Channel-specific and cumulative TAPS exposure were the primary exposures of the study. Six multivariate logistic regression analyses were performed to examine current and ever cigarette use outcome with exposure to TAPS. Six binary logistic regression analyses were applied to determine the susceptibility to cigarette use when exposed to TAPS.

Results:

Channel-specific TAPS analyses show that indirect TAPS increases the odds of all the three outcomes; current cigarette use (OR=1.68, 95% CI=1.10-2.58), ever cigarette use (OR=1.81, 95% CI=1.23-2.65) and susceptibility to cigarette use (OR=1.65, 95% CI=1.25-2.19) after adjusting for the covariates. Television (TV) and movies exposure decreases the odds of susceptibility to cigarette use (OR=0.55, 95% CI=0.31-0.97). Cumulative TAPS analyses show that exposure to 5 sources of TAPS increases the odds of current cigarette use (OR=2.53, 95% CI=1.21-5.29). Being male increases the odds of all the three outcomes; current (OR=3.52, 95% CI=2.11-5.87), ever (OR=2.51, 95% CI=1.69-3.73) and susceptibility to cigarette use (OR=1.31, 95% CI=1.01-1.69). Social influence is likely to increase current (OR=6.47, 95% CI=2.50-16.74), ever (OR=1.79, 95% CI=1.10-2.93) and susceptibility to cigarette use (OR=1.66, 95% CI=1.25-2.21).

Conclusion:

Indirect TAPS exposure increased the current, ever, and susceptibility to cigarette use among Nepalese adolescents. Overall, the current use of cigarettes followed a dose-response relationship with TAPS exposure. The result implies a requirement of active surveillance of tobacco products and future research on adolescent-focused tobacco marketing in Nepal.

Organizational and Financial Analysis of Polish Tobacco Control Program in 2000-2018

In accordance with the provisions of the WHO Framework Convention on Tobacco Control (FCTC), each country shall promote and strengthen public awareness of tobacco control issues (Article 12). Many parties to the FCTC have adopted national tobacco control programs to organize their tobacco control activities. The aim of our study was to analyze the organization and funding of the Polish Tobacco Control Program in years 2000-2018. Document analysis of The Program and reports from its implementation were performed in accordance to the Agency for Health Technology Assessment in Poland (AHTAPol) recommendations and the WHO FCTC guidelines for Article 12 implementation. Spending was also analyzed. The study showed both inadequate planning of and funding for Polish Tobacco Control Program. The Program was developed without use of best practices detailed in the WHO FCTC guidelines as well as in national guidelines prepared by AHTAPol. The experience of Poland shows that although earmarking tobacco taxes has existed in the law, it has been largely ineffective due to the poor Tobacco Control Program design and insufficient funding resulting from a poor execution of the earmarking law. This may be a warning to other countries to strive to create law, compliance with which can be verified and controlled.