"The law was actually drafted by us but the Government is to be congratulated on its wise actions": British American Tobacco and public policy in Kenya

A “willingness to be orchestrated”: Why are UK diplomats working with tobacco companies?

Background

The tobacco epidemic is global and addressing it requires global collaboration. International and national policies have been adopted to promote collaboration for tobacco control, including an obligation on diplomatic missions to protect public health from the vested interests of the tobacco industry. However, incidents of diplomats engaging with the tobacco industry are still occurring despite these regulations. This paper presents a case study of a British ambassador actions, and it points to some of the challenges researchers face in monitoring such incidents.

Methods

The incident studied in this paper was first identified through regular media monitoring conducted by the Tobacco Control Research Group at the University of Bath. The incident was further investigated by using the tools made available by the United Kingdom (UK) Freedom of Information Act, including submitting a request, asking for internal review, and submitting a complaint to the Information Commissioner's Office.

Results

We identified clear evidence of the UK ambassador to Yemen opening a cigarette factory, part owned by British American Tobacco (BAT), in Jordan. Our investigation revealed a lack of documentation of this and similar incidents of interaction between diplomats and the tobacco industry. We raise concerns about the actions of diplomats which contravene both national and international policies.

Discussion

Monitoring and reporting such activities produces several challenges. Diplomats' interactions with the tobacco industry represent a major concern for public health as such interactions seem to be systematically repeated. This paper calls for action to better implement national and international policies to protect the public health including in low- and middle-income countries (LMICs).

Tobacco industry thwarts ad ban legislation in India in the 1990s: Lessons for meeting FCTC obligations under Articles 13 and 5.3

Bans on tobacco advertising are important for reducing tobacco-caused disease. Previously secret internal tobacco industry documents and organizational and newspaper websites related to tobacco control efforts in India during 1990s were analyzed. The Ministry of Health and Family Welfare, World Health Organization, Indian Council of Medical Research, and civil society played important roles in pushing for tobacco control legislation beginning in the 1980s. Guided by transnational tobacco companies, especially British American Tobacco, Philip Morris International, and RJ Reynolds, Indian cigarette companies formed the Tobacco Institute of India (TII). Following the industry's global strategy, TII proposed voluntary advertising codes, used diplomatic channels and high level political and judicial lobbying, and allied with other industry, sports and trade groups to delay legislation for ten years. TII argued for the social and economic importance of tobacco and that laws were unnecessary, unconstitutional, and would hurt the economy. These early global strategies were continuing in 2022 to delay and evade legislative efforts to ban tobacco advertising. Understanding these strategies can inform public health efforts to counter industry efforts to thwart the WHO Framework Convention on Tobacco Control in 2022 not only in India, where the Ministry of Health and Family Welfare has proposed strengthening India's tobacco control law, but globally.

Application of the theory of planned behavior to predict smoking intentions: cross-cultural comparison of Kenyan and American young adults

Despite well-established research on the applications of the theory of planned behavior (TPB) in the American culture, TPB has not been fully tested in the Kenyan culture. This study compared the applications of TPB in predicting smoking intentions (i.e., future and weekend smoking intentions) of Kenyan and American young adults. Data were collected from 252 Kenyans and 227 Americans. The Kenyan participants consisted of 41.7% females with a mean age of 25 years (SD = 4.81). The American participants (49.3% females) had an average age of 19 years (SD = 1.30). Multi-group path analysis was performed to test the equivalence of a TPB-based mediation model in Kenyans and Americans. Significant differences of TPB application were detected. In the American model, smoking consequence beliefs were indirectly associated with smoking intentions through attitudes whereas neither direct nor indirect effects of smoking consequence beliefs were detected in the Kenyan model. Instead, normative beliefs indirectly associated with future and weekend smoking intentions through attitudes and subjective norms in the Kenyan model. Despite some overlapping paths, there were cultural variations on specific associations among TPB constructs between Kenyans and Americans. Cultural adaptations may be needed when applying TPB in the Kenyan cultural context.

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

BACKGROUND

The tobacco industry works to block, delay, and weaken national tobacco control legislation to implement the WHO Framework Convention on Tobacco Control (FCTC). This article reviews how Nepal overcame industry opposition and to a comprehensive tobacco control law implementing the FCTC.

METHODS

We triangulated newspaper articles and policy documents with key informant interviews.

RESULTS

With the support of international health groups, local tobacco control advocates worked with policymakers in Nepal to pass a comprehensive tobacco control law that exceeded FCTC obligations. The tobacco industry exploited a time of political transition to block consideration by Parliament, arranged and sponsored foreign tours for legislators, made death threats to tobacco control advocates and their families, and argued for the economic importance of tobacco farms. Despite strong interference from Health, and Law and Justice ministers, a 2009 Supreme Court ruling helped tobacco control advocates secure a comprehensive tobacco control law in 2011 that included rotating pictorial health warning labels covering 75% of both sides of cigarette packages, 100% smoke free public places and workplaces, private homes and vehicles, and a tobacco advertising, promotion, and sponsorship ban.

CONCLUSIONS

Advocates in developing countries should utilize Nepal's experience to reject tobacco industry offers of compromise and continue educating politicians and legislators to generate political support to pass a comprehensive tobacco control law. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak (the abstract in Nepali is available as a Supplementary Material).

IMPLICATIONS

The tobacco industry exploited a time of political transition in Nepal in its effort to block comprehensive tobacco control policy in Parliament by sponsoring foreign tours of legislatures, making death threats to tobacco control advocates and their families, and arguing for the economic importance of tobacco farms. Tobacco control advocates used litigation to raise awareness and educate legislators and promote strong legislation with the involvement of international health groups. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak.

'As Long as It Comes off as a Cigarette Ad, Not a Civil Rights Message': Gender, Inequality and the Commercial Determinants of Health

Scholarship on the commercial determinants of health (CDoH) has sought to understand the multiple ways corporate policies, practices and products affect population health. At the same time, gender is recognised as a key determinant of health and an important axis of health inequalities. To date, there has been limited attention paid to the ways in which the CDoH engage with and impact on gender inequalities and health. This review seeks to address this gap by examining evidence on the practices and strategies of two industries-tobacco and alcohol-and their interaction with gender, with a particular focus on women. We first describe the practices by which these industries engage with women in their marketing and corporate social responsibility activities, reinforcing problematic gender norms and stereotypes that harm women and girls. We then examine how tobacco and alcohol companies contribute to gender inequalities through a range of strategies intended to protect their market freedoms and privileged position in society. By reinforcing gender inequalities at multiple levels, CDoH undermine the health of women and girls and exacerbate global health inequalities.

Understanding Alternatives to Tobacco Production in Kenya: A Qualitative Analysis at the Sub-National Level

Tobacco is a key cash crop for many farmers in Kenya, although there is a variety of challenges associated with tobacco production. This study seeks to understand alternatives to tobacco production from the perspective of government officials, extension officers, and farmers at the sub-national level (Migori, Busia, and Meru) in Kenya. The study analyzes data from qualitative key-informant interviews with government officials and extension officers (n = 9) and focus group discussions (FGDs) with farmers (n = 5). Data were coded according to pre-identified categories derived from the research aim, namely, opportunities and challenges of tobacco farming and alternative crops, as well findings that illustrate the policy environment that shapes the agricultural context in these regions. We highlight important factors associated with the production of non-tobacco agricultural commodities, including the factors that shape the ability of these non-agricultural commodities to serve as viable alternatives to tobacco. The results highlight the effect that several factors, including access to capital, markets, and governmental assistance, have on farmer decisions. The results additionally display the structured policy approaches that are being promoted in governmental offices towards agricultural production, as well as the institutional shortcomings that inhibit their implementation at the sub-national level.

The Economic Geography of Kenyan Tobacco Farmers' Livelihood Decisions

INTRODUCTION

The narrative of prosperous economic livelihood of tobacco farmers in Kenya as alleged by the tobacco industry deserves challenge as evidence increasingly suggests that smallholder tobacco farmers are making little or no profits. Article 17 of the World Health Organization Framework Convention on Tobacco Control encourages viable alternative livelihoods for tobacco farmers. There is little evidence, however, on how tobacco farmers make livelihood choice decisions.

METHODS

A total of 527 purposefully selected smallholder tobacco farmers in Kenya from three main tobacco-growing regions participated in a 2017 economic livelihood survey. Geo-economic data were matched to surveyed farmers' Global Positioning System coordinates to estimate each farmer's access to nearby economic centers. Ownership of cell phones or radios was also used to estimate farmers' virtual access to nearby economic activities to understand better the role of information. Multivariate logistic regressions were used to control socioeconomic status and self-reported activity in nearby economic centers.

RESULTS

Tobacco farmers rarely live within 10 km of an economic center. Results suggest that the further away farmers live from economic centers, the less likely they are to grow tobacco, but more likely to grow tobacco under contract. Also, farmers owning a cell phone or radio are not only less likely to grow tobacco, but also to not engage in farming under contract if they do grow tobacco.

CONCLUSIONS

Physical and virtual access to nearby economic activities is significantly associated with tobacco farmers' livelihood choice decision and should be taken into consideration by decision makers while developing interventions for FCTC Article 17.

IMPLICATIONS

Smallholder tobacco farmers in lower-income countries are making little or no profits, but few studies have been conducted to illuminate what perpetuates tobacco production, with such studies urgently needed to support governments to develop viable alternative livelihoods for tobacco farmers. This study suggests that geographic and technological factors that shape farmers' economic decisions can help policy makers tailor alternative livelihood policies to different regional contexts and should be a focus of future research in this area.

Advertising Restrictions and Market Concentration in the Cigarette Industry: A Cross-Country Analysis

There has been a large increase in the adoption of tobacco advertising restrictions worldwide over the last two decades. Much of the literature studies their direct effect on cigarette demand. This paper investigates the indirect effect of advertising restrictions by evaluating the effect of the policies on the degree of concentration in the tobacco market. By using the variation between countries in timing of adoption of advertising restrictions, I estimate difference-in-difference models to examine the effect of an advertising ban on market-concentration, as measured by HHI. I find that advertising bans lead to an increase in market-concentration: HHI increased by 0.06 points for countries that adopted a ban between 2001 and 2017 conditional on trade and socio-economic characteristics, representing a 13% increase with respect to the mean (0.44). The effect is higher in developing countries (0.08 points increase). Further, I find that 'comprehensive' restrictions have a stronger impact on concentration, and 'limited' restrictions have little or no impact. These findings point to an important trade-off for policymakers: on one hand, advertising restrictions are likely to reduce consumption of cigarettes; on the other hand, due to an increase in market-concentration, they may be giving more power to tobacco companies.

Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review

Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.

Costs, contracts and the narrative of prosperity: an economic analysis of smallholder tobacco farming livelihoods in Kenya

BACKGROUND

The tobacco industry has used the alleged negative impacts on economic livelihoods for tobacco farmers as a narrative to oppose tobacco control measures in low/middle-income countries. However, rigorous empirical evidence to support or refute this claim remains scarce. Accordingly, we assess how much money households earn from selling tobacco, and the costs they incur to produce the crop, including labour inputs. We also evaluate farmers' decision to operate under contract directly with tobacco manufacturers and tobacco leaf-buying companies or to operate as independent farmers.

METHODS

A stratified random sampling method was used to implement a nationally representative household-level economic survey of 585 farmers across the three main tobacco growing regions in Kenya. The survey was augmented with focus group discussions in all three regions to refine and enrich the context of the findings.

RESULTS

Both contract and independent farmers experience small profit margins per acre, with contract farmers operating at a loss. Even when family labour is excluded from the calculation, income levels remain low, particularly considering the typically large households. Generally, tobacco farmers enter into contracts with tobacco companies because they have a 'guaranteed' buyer for their tobacco leaf and receive the necessary agricultural inputs (fertiliser, seeds, herbicides and so on) without paying cash up-front.

CONCLUSIONS

Tobacco farming households enter into contract with tobacco companies to realise perceived economic benefits. The narrative that tobacco farming is a lucrative economic undertaking for smallholder farmers, however, is inaccurate in the context of Kenya.

A Qualitative Analysis of Selected Stakeholders’ Viewpoints on Tobacco Control in Nigeria

Nigeria is a signatory to the Framework Convention on Tobacco Control. However, tobacco control efforts have been fraught with challenges. These challenges cannot be presumed to be independent of tobacco industry manipulation. We examined submissions and viewpoints from prominent tobacco control stakeholders across social, administrative, and political strata to identify convergence with tobacco industry viewpoints. We illustrate how these convergences pose a threat to effective tobacco control in Nigeria. A thematic analysis of stakeholder viewpoints was conducted on submissions to the national assembly during the Tobacco Control Bill public hearings and various industry documents. Areas of convergence with tobacco industry narratives were then explored. Significant convergence in views was observed between government agencies, social groups, and the tobacco industry. These were for narratives on constitution of a National Tobacco Control Committee, use of automated vending machines, designation of smoking areas, report to regulatory agencies, and negative effect of tobacco control on trade and poverty. There was evidence of tobacco industry interference in tobacco control efforts, which manifested in some prominent tobacco control stakeholders adopting the narratives of the tobacco industry. We advocate a constant watchfulness over the activities of these stakeholders and a proactive engagement with evidence-based antitobacco dialogue.

Avoiding "A Massive Spin-Off Effect in West Africa and Beyond": The Tobacco Industry Stymies Tobacco Control in Nigeria

Background

Nigeria plays important economic and political roles in Africa and is a significant market for the tobacco industry. This study describes the tobacco industry's efforts to block Nigeria's early tobacco control attempts, especially the Tobacco Smoking (Control) Decree 20 of 1990, and efforts to strengthen the Decree in 1995.

Method

Analysis of documents from the Truth Tobacco Documents Library and other Internet resources related to Nigeria's Decree 20 and earlier tobacco control efforts.

Results

The World Conferences on Smoking and Health and World Health Organization in the late 1970s spurred the Nigerian government to take steps towards tobacco regulation. In response, the tobacco industry lobbied government ministries, used front groups and its trade group, the Tobacco Advisory Council of Nigeria, to block and weaken government efforts. The industry obtained a draft of Decree 20 two years before it was enacted, considered the Decree anti-business and proposed language that led to the passage of a weaker Decree in 1990. It also attempted to influence a potential review of the Decree in 1995.

Conclusion

Decree 20 was a strong law for its time, but was weakened due to tobacco industry interference. Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, and enacted a comprehensive National Tobacco Control Act (NTCA) in May 2015. Lessons learned from Decree 20's experience should be applied to protect NTCA 2015, and in compliance with WHO FCTC Article 5.3 which require parties to protect tobacco control policies from tobacco industry interference.

Implications

This is the first detailed account of tobacco industry interference with tobacco legislation in Africa. The emergence of tobacco control in Nigeria threatened the tobacco industry, which believed that success in Nigeria would have a "domino effect" in Africa. The industry used lobbying and front groups to successfully block and weaken Nigeria's tobacco control, especially the Tobacco Smoking (Control) Decree 20 of 1990 and efforts to strengthen it in 1995. Nigeria and other African countries must learn from this history to protect tobacco control policies from the tobacco industry's vested interests and vigorously implement Article 5.3 of the WHO FCTC.

Tobacco consumption and nicotine dependence in Bengo Province, Angola: A community-based survey

There is concern about the potentially increasing use of tobacco in Angola. However, information on the frequency and determinants of this use is not systematised. This study aimed to estimate the prevalence of tobacco consumption and nicotine dependence among smokers in an Angolan population and considering individual socio-demographic and behavioural characteristics. A community-based survey with 2,472 respondents (age range: 15-64 years) was conducted in 2013-2014 in the country's Bengo Province. The collection methodology for assessing each type of tobacco consumption and its daily quantification followed the World Health Organization STEPwise approach to chronic disease risk factor surveillance. The Fagerström Test for Nicotine Dependence was also used to assess smokers. Mean values for prevalence of tobacco use and nicotine dependence were estimated by sex and by previously defined variables. Daily smoking (6.1%) was found to be higher for males (10.0%) them among females (2.6%), and the amount of ex-smokers (7.5%) was higher them smokers. Only 0.2% of those surveyed reported use of smokeless (chewing) tobacco. One-third of ever-smokers reported having started smoking daily before age 18. Nicotine dependence levels were classified as very low or low in 83.6% of the smokers. Daily smoking prevalence increased with age, and was higher in rural areas and among individuals with no formal education, lower incomes, and alcohol consumption. This population presented a low smoking prevalence, along with a low number of daily smoked cigarettes and low levels of nicotine dependency, despite the low prices of, and easy access to, manufactured cigarettes. These two factors conjugated with the current absence of an Angolan policy for tobacco control, enhance the susceptibility for rising overall tobacco use in the near future.

Tobacco growing and the sustainable development goals, Malawi

Negative impacts of tobacco result from human consumption and from tobacco-growing activities, most of which now occur in low- and middle-income countries. Malawi is the world's largest producer of burley tobacco and its population is affected by the negative consequences of both tobacco consumption and production. In countries like Malawi, tobacco control refers to control of the tobacco supply chain, rather than control of consumption. We review the impact of tobacco cultivation, using Malawi as an example, to illustrate the economic, environmental, health and social issues faced by low- and middle-income countries that still produce significant tobacco crops. We place these issues in the context of the sustainable development goals (SDGs), particularly 3a which calls on all governments to strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control. Other goals address the negative effects that tobacco cultivation has on development. The SDGs offer an opportunity for low- and middle-income countries that are dependent on tobacco production and that are not yet parties to the Convention, to reconsider joining the FCTC.

Analysis of British American Tobacco's questionable use of privilege and protected document claims at the Guildford Depository

Background

Tobacco companies have a documented history of attempting to hide information from public scrutiny, including inappropriate privilege claims. The 1998 Minnesota Consent Judgement created two depositories to provide public access to discovered documents. Users raised concerns about the access conditions and ongoing integrity of the Guildford Depository collection operated until 2015 by British American Tobacco (BAT).

Methods

A metadata search of the Legacy Tobacco Documents Library identified inconsistent privilege claims, and duplicates of documents withheld by BAT from public visitors. A review of the validity of claims, for documents obtained through these searches, was conducted against recognised legal definitions of privilege.

Findings

BAT has asserted inappropriate privilege claims over 49% of the documents reviewed (n=63). The quantity of such claims and consistency of the stated rationale for the privilege claims suggest a concerted effort rather than human error.

Conclusions

There was insufficient attention given to the operation of the Guildford Depository by the original plaintiffs, including to the subsequent use of privilege claims. Appropriate access to these documents, commensurate with the terms of legal settlements creating the collection, was critical given their public interest value for enhancing understanding of industry strategies and activities, informing of policy interventions, and for holding the industry to account. Future legal settlements should prevent defendants from subsequently withholding disclosed documents, aside from those legitimately privileged, from public view. Control of publicly disclosed documents should not be placed back into the hands of defendant tobacco companies. Plaintiffs also need to invest adequate resources into policing claims of legal privilege.

The role of public law-based litigation in tobacco companies' strategies in high-income, FCTC ratifying countries, 2004-14

Background

Tobacco companies use a host of strategies to undermine public health efforts directed to reduce and eliminate smoking. The success, failure and trends in domestic litigation used by tobacco companies to undermine tobacco control are not well understood, with commentators often assuming disputes are trade related or international in nature. We analyse domestic legal disputes involving tobacco companies and public health actors in high-income countries across the last decade to ascertain the types of action and the success or failure of cases, develop effective responses.

Methods

WorldLii, a publicly available online law repository, was used to identify domestic court cases involving tobacco companies from 2004 to 2014, while outcome data from LexisNexis and Westlaw databases were used to identify appeals and trace case history.

Results

We identified six domestic cases in the UK, Australia and Canada, noting that the tobacco industry won only one of six cases; a win later usurped by legislative reform and a further court case. Nevertheless, we found cases involve significant resource costs for governments, often progressing across multiple jurisdictional levels.

Discussion

We suggest that, in light of our results, while litigation takes up significant time and incurs legal costs for health ministries, policymakers must robustly fend off suggestions that litigation wastes taxpayers' money, pointing to the good prospects of winning such legal battles.

Exposing and addressing tobacco industry conduct in low-income and middle-income countries

The tobacco industry's future depends on increasing tobacco use in low-income and middle-income countries (LMICs), which face a growing burden of tobacco-related disease, yet have potential to prevent full-scale escalation of this epidemic. To drive up sales the industry markets its products heavily, deliberately targeting non-smokers and keeps prices low until smoking and local economies are sufficiently established to drive prices and profits up. The industry systematically flaunts existing tobacco control legislation and works aggressively to prevent future policies using its resource advantage to present highly misleading economic arguments, rebrand political activities as corporate social responsibility, and establish and use third parties to make its arguments more palatable. Increasingly it is using domestic litigation and international arbitration to bully LMICs from implementing effective policies and hijacking the problem of tobacco smuggling for policy gain, attempting to put itself in control of an illegal trade in which there is overwhelming historical evidence of its complicity. Progress will not be realised until tobacco industry interference is actively addressed as outlined in Article 5.3 of the Framework Convention on Tobacco Control. Exemplar LMICs show this action can be achieved and indicate that exposing tobacco industry misconduct is an essential first step.

The global tobacco control 'endgame': change the policy environment to implement the FCTC

The World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) has prompted major change in tobacco control globally. However, policy implementation has been uneven, making 'smoke free' outcomes possible in some countries, but not others. We identify the factors that would improve implementation. We describe an ideal type of 'comprehensive tobacco control regimes', where policy environments are conducive to the implementation of tobacco control measures designed to eradicate tobacco use. The ideal type requires that a country have certain policy processes: the department of health takes the policy lead; tobacco is 'framed' as a public health problem; public health groups are consulted at the expense of tobacco interests; socioeconomic conditions are conducive to policy change; and, the scientific evidence is 'set in stone' within governments. No country will meet all these criteria in the short term, and the gap between the ideal type and the current state is wide in many countries. However, the WHO experience provides a model for progress.

Tobacco control research in Kenya: the existing body of knowledge

This review examines the existing tobacco control research done in the country. It further identifies key gaps present in research and gives recommendations on priority research areas required to implement effective tobacco control programmes. Published literature, technical reports and reports by the Ministry of Health were reviewed. It included studies that measure tobacco use and its effects, monitor progress of tobacco control, or articles that are discussing tobacco control policy. The review was conducted in January 2013 and included 18 papers. There are six studies that assessed the prevalence of current tobacco consumption which yielded prevalence's of between 3.8%-19%. Only one study tried to determine an association between Tobacco use and Health. Studies that monitored progress of legislation indicated that the country lacked coordinated efforts for tobacco control, enforcement was weak and monitoring of the existing tobacco legislation was poor. This review has demonstrated that Kenya has made efforts to generate knowledge on tobacco control through research. However there is lack of research that demonstrates the effects of tobacco consumption on health and studies that detail the impact of the various tobacco control interventions.

Using findings from a public opinion poll to build political support for tobacco control policy in Kenya

OBJECTIVE

To assess the level of public support for tobacco control policies and to discuss how these findings could be used to influence the legislative process in the passing of tobacco control law in the country.

METHODS

A cross-sectional study conducted in Kenya between March and May 2007 on a random sample of 2021 (991 men and 1030 women) respondents aged 18 years and above. Interviews were done using a structured questionnaire by a research consultancy firm with long-standing experience in public polling.

RESULTS

The majority of respondents supported tobacco control policies as proposed by WHO Framework Convention on Tobacco Control. For example, 95% of the respondents supported smoking restrictions in all enclosed public places and workplaces, 94% supported visible health warnings on tobacco product packages, 83% supported a ban on advertisements of cigarettes and tobacco products and 69% supported a ban on sponsorship of events by tobacco companies. However, 60% perceived that there was very little commitment by legislators to tobacco control.

CONCLUSIONS

There was overwhelming public support for tobacco control policies and a general view that government was not doing enough in implementing policies to protect the public from tobacco harm. This public opinion poll was used as an advocacy tool to generate support among legislators for national tobacco control law.

Smoking prevention and cessation in the Africa and Middle East region: a consensus draft guideline for healthcare providers--executive summary

Despite the abundance of scientific evidence confirming the health consequences of smoking and other forms of tobacco use, the tobacco epidemic remains an important public health problem and by 2030 it is predicted that more than 80% of tobacco deaths will be in developing countries. In Africa and the Middle East, many local factors contribute to the initiation and maintenance of tobacco use. Although efforts to reduce the mortality and morbidity associated with smoking and tobacco dependence are underway, there is a need for guidance on how to utilize appropriate tobacco control policies and psychology- and pharmacology-based therapies to counter tobacco dependence as recommended by the Framework Convention on Tobacco Control (FCTC). A group of tobacco cessation experts from public health services and/or academic institutions in Africa and the Middle East participated in a series of four meetings held in Cairo, Cape Town, and Dubai between May 2008 and February 2011 to develop a draft guideline tailored to their region. This article provides the background to the development of this draft smoking cessation guideline and discusses how the recommendations can be implemented and progress monitored to promote both primary prevention and cessation of tobacco use within our countries. The draft guideline for Africa and the Middle East provides an important resource in combating the devastating effects of tobacco use in these regions which can be further localized through engagement with local stakeholders in the countries of the region.

The vector of the tobacco epidemic: tobacco industry practices in low and middle-income countries

PURPOSE

To understand transnational tobacco companies' (TTCs) practices in low and middle-income countries which serve to block tobacco-control policies and promote tobacco use.

METHODS

Systematic review of published research on tobacco industry activities to promote tobacco use and oppose tobacco-control policies in low and middle-income countries.

RESULTS

TTCs' strategies used in low and middle-income countries followed four main themes-economic activity; marketing/promotion; political activity; and deceptive/manipulative activity. Economic activity, including foreign investment and smuggling, was used to enter new markets. Political activities included lobbying, offering voluntary self-regulatory codes, and mounting corporate social responsibility campaigns. Deceptive activities included manipulation of science and use of third-party allies to oppose smoke-free policies, delay other tobacco-control policies, and maintain support of policymakers and the public for a pro-tobacco industry policy environment. TTCs used tactics for marketing, advertising, and promoting their brands that were tailored to specific market environments. These activities included direct and indirect tactis, targeting particular populations, and introducing new tobacco products designed to limit marketing restrictions and taxes, maintain the social acceptability of tobacco use, and counter tobacco-control efforts.

CONCLUSIONS

TTCs have used similar strategies in high-income countries as these being described in low and middle-income countries. As required by FCTC Article 5.3, to counter tobacco industry pressures and to implement effective tobacco-control policies, governments and health professionals in low and middle-income countries should fully understand TTCs practices and counter them.

Implementation of the framework convention on tobacco control in Africa: current status of legislation

OBJECTIVE

To describe, as of July 2011, the status of tobacco control legislation in Africa in three key areas of the Framework Convention on Tobacco Control (FCTC)-(1) Protection from exposure to tobacco smoke, (2) Packaging and labelling of tobacco products, and (3) Tobacco advertising, promotion and sponsorship.

METHODS

Review and analysis of tobacco control legislation in Africa, media reports, journal articles, tobacco industry documents and data published in the 2011 WHO Report on the Global Tobacco Epidemic.

RESULTS

Modest progress in FCTC implementation in Africa with many countries having legislation or policies on the protection from exposure to tobacco smoke, however, only a handful of countries meet the standards of the FCTC Article 8 and its Guidelines particularly with regards to designated smoking areas. Little progress on packaging and labelling of tobacco products, with few countries having legislation meeting the minimum standards of the FCTC Article 11 and its Guidelines. Mauritius is the only African country with graphic or pictorial health warnings in place and has the largest warning labels in Africa. Slightly better progress in banning tobacco advertising, promotion and sponsorship has been shown by African countries, although the majority of legislation falls short of the standards of the FCTC Article 13 and its Guidelines. Despite their efforts, African countries' FCTC implementation at national level has not matched the strong regional commitment demonstrated during the FCTC treaty negotiations.

CONCLUSION

This study highlights the need for Africa to step up efforts to adopt and implement effective tobacco control legislation that is fully compliant with the FCTC. In order to achieve this, countries should prioritise resources for capacity building for drafting strong FCTC compliant legislation, research to inform policy and boost political will, and countering the tobacco industry which is a major obstacle to FCTC implementation in Africa.

Social responsibility in tobacco production? Tobacco companies' use of green supply chains to obscure the real costs of tobacco farming

BACKGROUND

Tobacco companies have come under increased criticism because of environmental and labour practices related to growing tobacco in developing countries.

METHODS

Analysis of tobacco industry documents, industry websites and interviews with tobacco farmers in Tanzania and tobacco farm workers, farm authorities, trade unionists, government officials and corporate executives from global tobacco leaf companies in Malawi.

RESULTS

British American Tobacco and Philip Morris created supply chains in the 1990 s to improve production efficiency, control, access to markets and profits. In the 2000s, the companies used their supply chains in an attempt to legitimise their portrayals of tobacco farming as socially and environmentally friendly, rather than take meaningful steps to eliminate child labour and reduce deforestation in developing countries. The tobacco companies used nominal self-evaluation (not truly independent evaluators) and public relations to create the impression of social responsibility. The companies benefit from $1.2 billion in unpaid labour costs because of child labour and more than $64 million annually in costs that would have been made to avoid tobacco-related deforestation in the top 12 tobacco growing developing countries, far exceeding the money they spend nominally working to change these practices.

CONCLUSIONS

The tobacco industry uses green supply chains to make tobacco farming in developing countries appear sustainable while continuing to purchase leaf produced with child labour and high rates of deforestation. Strategies to counter green supply chain schemes include securing implementing protocols for the WHO Framework Convention on Tobacco Control to regulate the companies' practices at the farm level.

'A major lobbying effort to change and unify the excise structure in six Central American countries': How British American Tobacco influenced tax and tariff rates in the Central American Common Market

Background

Transnational tobacco companies (TTCs) may respond to processes of regional trade integration both by acting politically to influence policy and by reorganising their own operations. The Central American Common Market (CACM) was reinvigorated in the 1990s, reflecting processes of regional trade liberalisation in Latin America and globally. This study aimed to ascertain how British American Tobacco (BAT), which dominated the markets of the CACM, sought to influence policy towards it by member country governments and how the CACM process impacted upon BAT's operations.

Methods

The study analysed internal tobacco industry documents released as a result of litigation in the US and available from the online Legacy Tobacco Documents Library at http://legacy.library.ucsf.edu/. Documents were retrieved by searching the BAT collection using key terms in an iterative process. Analysis was based on an interpretive approach involving a process of attempting to understand the meanings of individual documents and relating these to other documents in the set, identifying the central themes of documents and clusters of documents, contextualising the documentary data, and choosing representative material in order to present findings.

Results

Utilising its multinational character, BAT was able to act in a coordinated way across the member countries of the CACM to influence tariffs and taxes to its advantage. Documents demonstrate a high degree of access to governments and officials. The company conducted a coordinated, and largely successful, attempt to keep external tariff rates for cigarettes high and to reduce external tariffs for key inputs, whilst also influencing the harmonisation of excise taxes between countries. Protected by these high external tariffs, it reorganised its own operations to take advantage of regional economies of scale. In direct contradiction to arguments presented to CACM governments that affording the tobacco industry protection via high cigarette tariffs would safeguard employment, the company's regional reorganisation involved the loss of hundreds of jobs.

Conclusions

Regional integration organisations and their member states should be aware of the capacity of TTCs to act in a coordinated transnational manner to influence policy in their own interests, and coordinate their own public health and tax policies in a similarly effective way.

The epidemiology of addiction in Sub-Saharan Africa: a synthesis of reports, reviews, and original articles

Use of alcohol and other psychoactive substances is associated with serious social and public health problems, but the extent of the problem in Sub-Saharan Africa is not well known. We set out to review epidemiological publications on alcohol and other psychoactive substances in Sub-Saharan Africa by performing a systematic search of electronic databases and paper records. Ten Sub-Saharan African countries are among the 22 in the world with the highest increase in per capita alcohol consumption. Cannabis, tobacco, and khat are widely used, and use of cocaine, stimulants, and heroin is increasing. More epidemiological research and implementation and evaluation of interventions is needed. Collaboration between African researchers and those in developed countries could help. 

Status of implementation of Framework Convention on Tobacco Control (FCTC) in Ghana: a qualitative study

Background

The Framework Convention on Tobacco Control (FCTC), a World Health Organization treaty, has now been ratified by over 165 countries. However there are concerns that implementing the Articles of the treaty may prove difficult, particularly in the developing world. In this study we have used qualitative methods to explore the extent to which the FCTC has been implemented in Ghana, a developing country that was 39^th to ratify the FCTC, and identify barriers to effective FCTC implementation in low income countries.

Methods

Semi-structured interviews with 20 members of the national steering committee for tobacco control in Ghana, the official multi-disciplinary team with responsibility for tobacco control advocacy and policy formulation, were conducted. The Framework method for analysis and NVivo software were used to identify key issues relating to the awareness of the FCTC and the key challenges and achievements in Ghana to date.

Results

Interviewees had good knowledge of the content of the FCTC, and reported that although Ghana had no explicitly written policy on tobacco control, the Ministry of Health had issued several tobacco control directives before and since ratification. A national tobacco control bill has been drafted but has not been implemented. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritisation of tobacco control efforts, leading to slow implementation of the treaty.

Conclusion

Whilst Ghana has ratified the FCTC, there is an urgent need for action to pass a national tobacco control bill into law to enable it to implement the treaty, sustain tobacco control efforts and prevent Ghana's further involvement in the global tobacco epidemic.

Corporate Power and Social Policy: The Political Economy of the Transnational Tobacco Companies

Drawing on published tobacco document research and related sources, this article applies Farnsworth and Holden's conceptual framework for the analysis of corporate power and corporate involvement in social policy (2006) to the transnational tobacco companies (TTCs). An assessment is made of TTCs' structural power, the impact upon their structural position of tobacco control (TC) policies, and their use of agency power. The analysis suggests that, as a result of the growth of TC policies from the 1950s onwards, TTCs have had to rely on political agency to pursue their interests and attempt to reassert their structural position. The collapse of the Eastern bloc and the liberalisation of East Asian economies presented new structural opportunities for TTCs in the 1980s and 1990s, but the development of globally coordinated TC policies facilitated by the World Health Organisation's Framework Convention on Tobacco Control has the potential to constrain these.

Trafficking in tobacco farm culture: Tobacco companies use of video imagery to undermine health policy

The cigarette companies and their lobbying organization used tobacco industry-produced films and videos about tobacco farming to support their political, public relations, and public policy goals. Critical discourse analysis shows how tobacco companies utilized film and video imagery and narratives of tobacco farmers and tobacco economies for lobbying politicians and influencing consumers, industry-allied groups, and retail shop owners to oppose tobacco control measures and counter publicity on the health hazards, social problems, and environmental effects of tobacco growing. Imagery and narratives of tobacco farmers, tobacco barns, and agricultural landscapes in industry videos constituted a tobacco industry strategy to construct a corporate vision of tobacco farm culture that privileges the economic benefits of tobacco. The positive discursive representations of tobacco farming ignored actual behavior of tobacco companies to promote relationships of dependency and subordination for tobacco farmers and to contribute to tobacco-related poverty, child labor, and deforestation in tobacco growing countries. While showing tobacco farming as a family and a national tradition and a source of jobs, tobacco companies portrayed tobacco as a tradition to be protected instead of an industry to be regulated and denormalized.

Smoking in Ghana: a review of tobacco industry activity

Background:

African countries are a major potential market for the tobacco industry, and the smoking epidemic is at various stages of evolution across the continent. Ghana is an African country with a low prevalence of smoking despite an active tobacco industry presence for over 50 years. This study explores potential reasons for this apparent lack of industry success.

Objective:

To explore the history of tobacco industry activity in Ghana and to identify potential reasons for the current low prevalence of smoking.

Methods:

A search was made of tobacco industry archives and other local sources to obtain data relevant to marketing and consumption of tobacco in Ghana.

Findings:

British American Tobacco, and latterly the International Tobacco Company and its successor the Meridian Tobacco Company, have been manufacturing cigarettes in Ghana since 1954. After an initial sales boom in the two decades after independence in 1957, the sustained further increases in consumption typical of the tobacco epidemic in most countries did not occur. Possible key reasons include the taking of tobacco companies into state ownership and a lack of foreign exchange to fund tobacco leaf importation in the 1970s, both of which may have inhibited growth at a key stage of development, and the introduction of an advertising ban in 1982. BAT ceased manufacturing cigarettes in Ghana in 2006.

Conclusion:

The tobacco industry has been active in Ghana for over 50 years but with variable success. The combination of an early advertising ban and periods of unfavourable economic conditions, which may have restricted industry growth, are likely to have contributed to the sustained low levels of tobacco consumption in Ghana to date.

Tobacco industry issues management organizations: creating a global corporate network to undermine public health

Background

The global tobacco epidemic claims 5 million lives each year, facilitated by the ability of transnational tobacco companies to delay or thwart meaningful tobacco control worldwide. A series of cross-company tobacco industry "issues management organizations" has played an important role in coordinating and implementing common strategies to defeat tobacco control efforts at international, national, and regional levels. This study examines the development and enumerates the activities of these organizations and explores the implications of continuing industry cooperation for global public health.

Methods

Using a snowball sampling strategy, we collected documentary data from tobacco industry documents archives and assembled them into a chronologically organized case study.

Results

The International Committee on Smoking Issues (ICOSI) was formed in 1977 by seven tobacco company chief executives to create common anti-tobacco control strategies and build a global network of regional and national manufacturing associations. The organization's name subsequently changed to INFOTAB. The multinational companies built the organization rapidly: by 1984, it had 69 members operating in 57 countries. INFOTAB material, including position papers and "action kits" helped members challenge local tobacco control measures and maintain tobacco-friendly environments. In 1992 INFOTAB was replaced by two smaller organizations. The Tobacco Documentation Centre, which continues to operate, distributes smoking-related information and industry argumentation to members, some produced by cross-company committees. Agro-Tobacco Services, and now Hallmark Marketing Services, assists the INFOTAB-backed and industry supported International Tobacco Growers Association in advancing claims regarding the economic importance of tobacco in developing nations.

Conclusion

The massive scale and scope of this industry effort illustrate how corporate interests, when threatened by the globalization of public health, sidestep competitive concerns to coordinate their activities. The global network of national and regional manufacturing associations created and nurtured by INFOTAB remains active, particularly in relation to the recently negotiated global health treaty, the Framework Convention on Tobacco Control. Policymakers should be aware that although these associations claim to represent only national or regional interests, they are allied to and coordinated with a confederation of transnational tobacco companies seeking to protect profits by undermining public health.