WHO FCTC article 5.3: promise but little progress

Awareness and Attitude Towards Tobacco Products and Tobacco Industry and Perception about Government's Role in Tobacco Control among the Adult Rural Population: A Cross-sectional Study in the Indian State of Bihar

Background

Attitudes and impressions toward the tobacco industry and tobacco products among the general public are important determinants for curbing the menace of the tobacco epidemic. Accordingly, this study aimed to assess the knowledge and perceptions about the tobacco industry and tobacco products and analyze attitudes towards social denormalization (SD) of tobacco use and tobacco industry denormalization (TID) among the rural population of Bihar, India.

Methods

This community-based cross-sectional survey was conducted on 421 adults aged 18 to 65 years who were selected using multistage systematic random sampling in a rural area of Bihar State in India from January to March 2022. Results were presented as proportions and the factors associated with support for TID and SD were identified using the chi-square test and binary logistic regression.

Findings

Out of 421 participants, 342 (81.2%) did not consider smokeless tobacco to be very dangerous. Nearly half (192, 45.6%) of the individuals believed that tobacco companies never tell the truth about the ill effects of tobacco use on health. Maximum, 345 (89.5%) also believed that the tobacco industry is responsible for adverse health effects of tobacco use and that the government should sue them. The prevalence of favorable attitudes toward TID and SD was found to be 55.1% [95% CI: 50.3% - 59.8%] and 38.2% [95% CI: 33.7% - 42.9%], respectively.

Conclusion

One out of every two and one out of every three individuals showed favorable attitudes toward TID and SD, respectively. There is a need to inform and educate the public on the ill effects of tobacco and the deceptive strategies used by the tobacco industry to help them choose health over tobacco.

Tobacco industry presence and practices in Mozambique: a 'chaotic' but worthy market

BACKGROUND

Mozambique has experienced a series of tobacco industry consolidations both in tobacco leaf buying and processing, and in cigarette manufacturing and marketing. The growth of the tobacco industry presence in Mozambique was followed by an increase in tobacco industry's Corporate Social Responsibility (CSR) activities. This is the first paper to describe the history of tobacco industry activities in Mozambique, a party to the WHO Framework Convention on Tobacco Control (FCTC).

METHODS

We reviewed industry documents and associated web-based information. Industry documents (1990-2021) were identified through University of California San Francisco's Truth Tobacco Industry Documents Library. We followed with a search of web-based sources pertaining to the tobacco industry in Mozambique. We complemented our analysis with select media sources to identify statements by government officials in relation to the tobacco industry. We mapped major tobacco industry players, industry partnerships and corresponding CSR activities.

RESULTS

Tobacco production increased substantially in Mozambique in the 1990s when tobacco companies began targeting African countries. The increased attention to tobacco production, trade and sales in Mozambique was coupled with greater industry involvement in CSR activities. We identified 10 tobacco industry CSR programmes in Mozambique. Most of the CSR programmes focus on health including HIV/AIDS, social issues and environmental issues.

CONCLUSIONS

Similar to other tobacco-growing countries, the industry facilitated an increase in tobacco production and continues efforts to increase the tobacco consumption market while engaging in CSR activities focused on social and environmental issues. As in other countries, CSR initiatives in Mozambique enhance industry's reputation. Importantly, these CSR programmes and partnerships breach national laws and the provisions of the FCTC. The continuation of these programmes suggests limited attention within government to protect public policy from industry interference in compliance with Article 5.3 of the FCTC.

'They have a right to participate as a stakeholder': Article 5.3 implementation and government interactions with the tobacco industry in Ethiopia

INTRODUCTION

This paper explores implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control in Ethiopia. The analysis highlights how operationalising key requirements of Article 5.3, such as minimising policy engagement with the tobacco industry, has been mediated by path-dependent processes of stakeholder consultation and collaboration that have persisted following privatisation of Ethiopia's state-owned tobacco monopoly.

METHODS

We conducted semistructured interviews with key officials (n=21) working in tobacco control policy, with high levels of access secured across ministries and agencies beyond health.

RESULTS

We found contrasting levels of awareness of Article 5.3 across government sectors, with extremely limited awareness in departments beyond health. The data also highlight competing ideas about conflict of interest, in which recognition of a fundamental conflict of interest with the tobacco industry is largely confined to health actors. Beyond limited cross-sectoral awareness and understanding of Article 5.3, gaps in implementation are exacerbated by assumptions and practices around stakeholder consultation, in which attempts to minimise policy interactions with the tobacco industry are mediated by institutionally embedded processes that presume active engagement. The results also highlight a continuation of the close relationship between the Ethiopian government and tobacco monopoly following its privatisation.

CONCLUSION

The Ethiopian government's recent achievements in tobacco control legislation require that policymakers are actively supported in reconciling perceived tensions and requirements for stakeholder consultation. Effective tobacco control governance would be further enhanced by enabling government agencies to more clearly identify which interactions with the tobacco industry are strictly necessary under Article 5.3 guideline recommendations.

Understanding the dynamics of notification and implementation of Article 5.3 across India's states and union territories

INTRODUCTION

In federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India's federal system, examining how its guidelines have been operationalised across states and union territories.

METHODS

Interviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019.

RESULTS

The data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of 'socially responsible' industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees.

CONCLUSION

The spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India's tobacco control legislation.

How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention

Alcohol, tobacco, and unhealthy foods contribute greatly to the global burden of non-communicable disease (NCD). Member states of the World Health Organization (WHO) have recognized the critical need to address these three key risk factors through global action plans and policy recommendations. The 2013-2020 WHO action plan identifies the need to engage economic, agricultural and other relevant sectors to establish comprehensive and coherent policy. To date one of the biggest barriers to action is not so much identifying affective policies, but rather how a comprehensive policy approach to NCD prevention can be established across sectors. Much of the research on policy incoherence across sectors has focused on exposing the strategies used by commercial interests to shape public policy in their favor. Although the influence of commercial interests on government decisions remains an important issue for policy coherence, we argue, that the dominant neoliberal policy paradigm continues to enable the ability of these interests to influence public policy. In this paper, we examine how this dominant paradigm and the way it has been enshrined in institutional mechanisms has given rise to existing systems of governance of product environments, and how these systems create structural barriers to the introduction of meaningful policy action to prevent NCDs by fostering healthy product environments. Work to establish policy coherence across sectors, particularly to ensure a healthy product environment, will require systematic engagement with the assumptions that continue to structure institutions that perpetuate unhealthy product environments.

Building capacity for applied research to reduce tobacco-related harm in low- and middle-income countries: the Tobacco Control Capacity Programme (TCCP)

Background

Tobacco use is the leading cause of preventable deaths in the world. By 2030, more than 80% of these tobacco-related deaths will occur in low- and middle-income countries (LMICs). The aim of the Tobacco Control Capacity Programme (TCCP) therefore, is to reduce tobacco-related mortality and morbidity by building research capacity in LMICs.

Methods

A consortium of fifteen partner organisations across eight countries (Bangladesh, Ethiopia, Ghana, India, South Africa, the Gambia, Uganda and the UK) will offer extensive research methods and leadership training opportunities to conduct high quality research projects on policy and practice and establish strong research partnerships. An example of one such study using a mixed method design to investigate tobacco industry interference in Uganda is presented.

Results

The TCCP programme will produce research that can inform policies and practice within countries to prevent or reduce tobacco use. By conducting research in three key areas (tobacco taxation, reducing illicit trade, and addressing tobacco industry interference, as well as other local priorities) the programme will help to reduce tobacco disease and death and also generate revenue for governments through taxation which aids other development priorities. While conducting research in LMICs on these themes TCCP will provide evidence to support better implementation of the Framework Convention for Tobacco Controls (FCTC), which will result in reductions in tobacco-related mortality and morbidity and also help generate revenue for governments through taxation which aids other development priorities.

Conclusion

The TCCP programme will create a cohort of skilled early-career researchers and research leaders who will build cohesive and successful research teams in LMICs. It will also create several collaborative networks of researchers, policy-makers and advocates to co-produce context-specific research on tobacco control and its translation into policy. This will advance implementation science in LMICs and improve population health. By generating context-specific evidence, the TCCP will support advocacy efforts to shift attitudes within communities and governments towards a stronger tobacco control. Policy makers will be assisted by the evidence generated in this programme to challenge aggressive tobacco industry tactics and implement effective tobacco control.

Memoranda of understanding: a tobacco industry strategy to undermine illicit tobacco trade policies

OBJECTIVE

Analyse the transnational tobacco companies' (TTCs) memoranda of understanding (MoUs) on illicit trade and how they could undermine the WHO Framework Convention on Tobacco Control (FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products (Protocol).

METHODS

Review of tobacco industry documents and websites, reports, news and media items using standard snowball search methods.

RESULTS

Facing increasing pressure from governments and the FCTC to address illicit tobacco trade during the late 1990s, TTCs entered into voluntary partnerships embodied in MoUs with governments' law enforcement and customs agencies. One of the earliest known MoUs was between Philip Morris International and Italy in 1999. TTCs agreed among themselves to establish MoUs individually but use the Italian MoU as a basis to establish similar connections with other governments to pre-empt more stringent regulation of illicit trade. TTCs report to have signed over 100 MoUs since 1999, and promote them on their websites, in Corporate Social Responsibility reports and in the media as important partnerships to combat illicit tobacco trade. There is no evidence to support TTCs' claims that these MoUs reduce illicit trade. The terms of these MoUs are rarely made public. MoUs are non-transparent partnerships between government agencies and TTCs, violating FCTC Article 5.3 and the Protocol. MoUs are not legally binding so do not create an accountability system or penalties for non-compliance, rendering them ineffective at controlling illicit trade.

CONCLUSION

Governments should reject TTC partnerships through MoUs and instead ratify and implement the FCTC and the Protocol to effectively address illicit trade in tobacco products.

Knowledge and risk perceptions of Israelis towards combustible cigarettes: the need for immediate remedial action

BACKGROUND

Devastation from the tobacco epidemic continues, with strong government tobacco control policy absent in most countries. Knowledge of the full scope of tobacco harm in populations may form the basis for healthier behavior, de-normalization of smoking, and a consensus about necessary public policy. However, many populations may be poorly-informed about the risks, and this ignorance may undermine both effective policy-making and implementation of tobacco control policies. We present knowledge and risk perceptions about smoking tobacco smoke exposure in Israel.

METHODS

A nationally-representative phone survey was conducted in Israel (n = 505; response rate = 61%). We assessed knowledge about active and passive smoking using four questions, three of which addressed knowledge about harm, and one of which addressed knowledge of tobacco-related harm relative to knowledge of harm due to traffic accidents. The three questions which addressed knowledge of harm were combined into a composite score. We also asked four risk perception questions concerning tobacco smoke exposure, which were measured on a 7-point Likert scale and then combined. Multivariable logistic regression and linear models were used to identify whether smoking status or socio-demographic variables were associated with knowledge of harm, comparative knowledge of harm, and risk perceptions.

RESULTS

Just two in five respondents, and one in five respondents who were current smokers, accurately answered three simple questions about harms of smoking. Fewer than three in ten respondents, and fewer than one in five smokers, knew that smoking causes more damage than traffic accidents. Many (30.3%) were unaware that tobacco smoke exposure causes both lung cancer and heart disease, 27.7% did not know that smoking both shortens life and injures quality of life, and 31.1% did not know that smoking-attributable health problems will afflict all or most heavy smokers. Overall, risk perceptions regarding tobacco smoke exposure were high (mean = 24.5, SD:4.5, on a scale of 7-28, with 28 the indicating highest level). Smoking status was consistently associated with lower levels of knowledge, comparative knowledge, and risk perceptions, with current smokers having the lowest levels of knowledge and the lowest risk perceptions.

CONCLUSIONS

Like many others, Israelis, and particularly Israeli smokers, do not fully grasp tobacco's true dangers. Effective communication of the full range of tobacco risks to the public, with a focus on communication with smokers, is an essential component of comprehensive tobacco control policy.

Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products

Background

Tobacco companies are introducing new ‘heat-not-burn’ cigarettes in dozens of countries. Historically, these products failed commercially, and independent researchers contested their health claims. The most prominent early heat-not-burn cigarette was RJ Reynolds’s (RJR’s) Premier, introduced in the USA in 1988. Curiously, The Lancet endorsed Premier as a ‘near-perfect low tar cigarette’ in a 1991 editorial, 2 years after Premier had been removed from the market. We examined the context of this endorsement.

Methods

To ascertain what RJR knew about this endorsement, we systematically searched and analysed previously secret RJR documents in public archives and triangulated the industry document data with other published work.

Results

RJR had a long-standing interest in collaborating with outside scientists to endorse potentially reduced harm cigarettes. The author of The Lancet editorial had previously corresponded with RJR regarding Premier’s health effects and market potential. Internally, RJR regarded The Lancet’s editorial, its stance on novel tobacco products, and its endorsement of Premier as major successes. While the editorial came too late to save Premier, RJR saw future business opportunities for novel products if endorsed by health authorities.

Conclusions

Endorsement by high-impact medical journals and health authorities may be critical in helping heat-not-burn’ products succeed where previous attempts have failed. Conflicts of interest influenced these endorsements in the past. Health leaders and academic journals should consider both conflicts of interest and the ethics of endorsing tobacco product substitution, as tobacco companies simultaneously work to promote cigarette smoking and undermine tobacco control globally.

Controlling corporate influence in health policy making? An assessment of the implementation of article 5.3 of the World Health Organization framework convention on tobacco control

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) stands to significantly reduce tobacco-related mortality by accelerating the introduction of evidence-based tobacco control measures. However, the extent to which States Parties have implemented the Convention varies considerably. Article 5.3 of the FCTC, is intended to insulate policy-making from the tobacco industry's political influence, and aims to address barriers to strong implementation of the Convention associated with tobacco industry political activity. This paper quantitatively assesses implementation of Article 5.3's Guidelines for Implementation, evaluates the strength of Parties' efforts to implement specific recommendations, and explores how different approaches to implementation expose the policy process to continuing industry influence.

METHODS

We cross-referenced a broad range of documentary data (including FCTC Party reports and World Bank data on the governance of conflicts of interest in public administration) against Article 5.3 implementation guidelines (n = 24) for 155 Parties, and performed an in-depth thematic analysis to examine the strength of implementation for specific recommendations.

RESULTS

Across all Parties, 16% of guideline recommendations reviewed have been implemented. Eighty-three percent of Parties that have taken some action under Article 5.3 have introduced less than a third of the guidelines. Most compliance with the guidelines is achieved through pre-existing policy instruments introduced independently of the FCTC, which rarely cover all relevant policy actors and fall short of the guideline recommendations. Measures introduced in response to the FCTC are typically restricted to health ministries and not explicit about third parties acting on behalf of the industry. Parties systematically overlook recommendations that facilitate industry monitoring.

CONCLUSION

Highly selective and incomplete implementation of specific guideline recommendations facilitates extensive ongoing opportunities for industry policy influence. Stronger commitment to implementation is required to ensure consistently strong compliance with the FCTC internationally.

Rhetoric and the law, or the law of rhetoric: How countries oppose novel tobacco control measures at the World Trade Organization

The tobacco industry has developed an extensive array of strategies and arguments to prevent or weaken government regulation. These strategies and arguments are well documented at the domestic level. However, there remains a need to examine how these arguments are reflected in the challenges waged by governments within the World Trade Organization (WTO). Decisions made at the WTO have the potential to shape how countries govern. Our analysis was conducted on two novel tobacco control measures: tobacco additives bans (Canada, United States and Brazil) and plain, standardized packaging of tobacco products (Australia, New Zealand, Ireland, EU and UK). We analyzed WTO documents (i.e. meeting minutes and submissions) (n = 62) in order to identify patterns of argumentation and compare these patterns with well-documented industry arguments. The pattern of these arguments reveal that despite the unique institutional structure of the WTO, country representatives opposing novel tobacco control measures use the same non-technical arguments as those that the tobacco industry continues to use to oppose these measures at the domestic level.

Assessment of the European Union's illicit trade agreements with the four major Transnational Tobacco Companies

To address the illicit cigarette trade, the European Union (EU) has signed agreements with the four major Transnational Tobacco Companies (TTCs) that involve establishing extensive systems of cooperation. All agreements foresee two types of payments: annual payments (totalling US$ 1.9 billion over 20 years) and supplementary seizure payments, equivalent to 100% of the evaded taxes in the event of seizures of their products. While limited by the fundamental lack of transparency in this area, our analysis suggests that these agreements have served largely to secure the TTCs' interests and are threatening progress in tobacco control. The seizure payments are paltry and a wholly inadequate deterrent to TTC involvement in illicit trade. Despite the agreements, growing evidence indicates the TTCs remain involved in the illicit trade or are at best failing to secure their supply chains as required by the agreements. The intention of the seizure-based payments to deter the tobacco industry from further involvement in the illicit cigarette trade has failed because the agreements contain too many loopholes that provide TTCs with both the incentive and opportunity to classify seized cigarettes as counterfeit. In addition, the shifting nature of cigarette smuggling from larger to smaller consignments often results in seizures that are too small to qualify for the payments. Consequently, the seizure payments represent a tiny fraction of the revenue lost from cigarette smuggling, between 2004 and 2012, 0.08% of the estimated losses due to illicit cigarette trade in the EU. Our evidence suggests the EU should end these agreements.

'A preferred consultant and partner to the Royal Government, NGOs, and the community': British American Tobacco's access to policy-makers in Cambodia

British American Tobacco Cambodia (BATC) has dominated the country's tobacco market since its launch in 1996. Aggressive marketing in a weak regulatory environment and strategies to influence tobacco control policy have contributed to an emerging tobacco-related public health crisis. Analysis of internal tobacco industry documents, issues of BATC's in-house newsletter, civil society reports and media demonstrate that BATC officials have successfully sought to align the company with Cambodia's increasingly controversial political and business leadership that is centred around the Cambodian People's Party with the aim of gaining access to policy-makers and influencing the policy process. Connections to the political elite have resulted in official recognition of the company's ostensible contribution to Cambodia's economic and social development and, more significantly, provided BATC with opportunities to petition policy-makers and to dilute tobacco control regulation. Corporate promotion of its contribution to Cambodia's economic and social development is at odds with its determined efforts to thwart public health regulation and Cambodia's compliance with the Framework Convention on Tobacco Control.

Tobacco industry interference with tobacco control policies in Poland: legal aspects and industry practices

Background

Since 2006, when Poland ratified the WHO Framework Convention on Tobacco Control (FCTC), there have been efforts to improve tobacco control regulation in the country. At the same time, at the European Union level, Poland took part in discussions over revision of the Tobacco Tax Directive and the Tobacco Products Directive. This study aims to explore the tobacco industry's tactics to interfere with the creation of those policies.

Methods

Analysis of 257 documents obtained through freedom of information request.

Results

We identified three means that the tobacco industry used to interfere with tobacco control policies: creating a positive attitude, expressing a will to be a part of the policymaking process, and exerting pressure. We found that those tactics have often been used unethically, with the industry providing the government with ready legislation proposals, overstating its contribution to the economy and the government revenues, misrepresenting the illicit cigarette problem and misusing scientific evidence. The industry also used legal threats, including use of bilateral trade agreements, against implementation of tobacco control measures. The companies lobbied together directly and through third parties, with the cigarette excise tax structure being the only area of disagreement among the companies. The industry also pushed the Polish government to challenge tobacco control policies in countries with stronger public policy standards, including UK display bans and the Australian plain-packaging law.

Conclusions

From an object of regulation, the tobacco industry in Poland became a partner with the government in legislative work. Implementation of provisions of Article 5.3 of the WHO FCTC could prevent further industry interference.

Tobacco policy in Israel: 1948-2014 and beyond

BACKGROUND

Tobacco is the only consumer product known to kill half of its users, and is a significant cause of death and disability to exposed nonsmokers. This presents a unique conundrum for modern democracies, which emphasize personal liberty, yet are obligated to protect citizens. In Israel, the death toll in 2014 from smoking is expected to reach 8000 deaths; nearly a fifth of the population smokes, and over two-thirds of the population are exposed to tobacco smoke.

AIM

This paper provides an overview of tobacco policy in Israel since the inception of the State, presents the development of the National Tobacco Control Plan, and recommends future actions.

METHODS

Sources for this article included the Knesset (Israeli Parliament) and Ministry of Health websites, Health Minister Reports to the Knesset on Smoking, and the scientific literature.

RESULTS

Israel has an impressive record on tobacco control policy, beginning with taxation in 1952, landmark smoke-free air and marketing legislation in the early 1980's, tax increases and expansions of smoke-free air and marketing legislation in the ensuing years, and the addition of subsidized smoking cessation technologies in 2010. Until 2011, actions were taken by various organizations without formal coordination; since the passage of the National Tobacco Control Plan in 2011, the Ministry of Health has held responsibility for coordinating tobacco control, with an action plan. The plan has been partially implemented. Smoke-free air laws were expanded, but enforcement is poor. Passage of critical marketing and advertising restrictions is stalled. Requested funds for tobacco control did not materialize.

RECOMMENDATIONS

In order to prevent hundreds of thousands of preventable premature deaths in the coming decades, Israel should considerably strengthen tobacco control policies to include: guaranteed funding for tobacco control; strong curbs on advertising, promotion and sponsorship of tobacco and smoking products; public education; law enforcement; protection of children from exposure to tobacco; regulation of electronic cigarettes and other alternative harm-reducing products; tobacco control research; and systematic monitoring of, and periodic updates to, the National Tobacco Control Plan. Israel should also begin discussions of Endgame scenarios, and consider abolition of tobacco, as it continues its progress towards making smoking history.

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.