State-ownership of tobacco industry: a ‘fundamental conflict of interest’ or a ‘tremendous opportunity’ for tobacco control?

Reductions in smoking due to ratification of the Framework Convention for Tobacco Control in 171 countries

Smoking globally kills over half of long-term smokers and causes about 7 million annual deaths. The World Health Organization Framework Convention for Tobacco Control (FCTC) is the main global policy strategy to combat smoking, but its effectiveness is uncertain. Our interrupted time series analyses compared before- and after-FCTC trends in the numbers and prevalence of smokers below the age of 25 years (when smoking initiation occurs and during which response to interventions is greatest) and on cessation at 45-59 years (when quitting probably occurs) in 170 countries, excluding China. Contrasting the 10 years after FCTC ratification with the income-specific before-FCTC trends, we observed cumulative decreases of 15.5% (95% confidence interval = -33.2 to -0.7) for the numbers of current smokers and decreases of -7.5% (95% CI = -10.6 to -4.5) for the prevalence of smoking below age 25 years. The quit ratio (comparing the numbers of former and ever smokers) at 45-59 years increased by 1.8% (1.2 to 2.3) 10 years after FCTC ratification. Countries raising taxes by at least 10 percentage points concurrent with ratification observed steeper decreases in all three outcomes than countries that did not. Over a decade across 170 countries, the FCTC was associated with 24 million fewer young smokers and 2 million more quitters.

A Critical Review of E-Cigarette Regulation in China: Challenges and Prospects for Youth Prevention and Tobacco Control

INTRODUCTION

The increasing popularity of electronic cigarettes (e-cigarettes) has led to the emergence of public health concerns, particularly among the youth. As a major producer and exporter of e-cigarettes, China has faced public health challenges in regulating the unregulated e-cigarette industry.

AIMS AND METHODS

This study aims to evaluate the regulatory development of e-cigarettes in China. We searched and obtained national policy documents related to e-cigarettes and subnational smoke-free laws from LexisNexis on August 2, 2023, which were enacted between January 1, 2023 and July 31, 2023. We used 99 policy documents for the final analysis, specifically 68 national policy documents on e-cigarettes and 31 subnational smoke-free laws. We chronologically reviewed these policy documents in full text and summarized them on the basis of their content and the requirements of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

RESULTS

Chinese policymakers established the current regulatory framework for e-cigarettes by amending, enacting, and enforcing laws and regulations. E-cigarettes are categorized as tobacco products, and the State Tobacco Monopoly Administration regulates the e-cigarette industry. The Chinese authorities prioritize youth prevention in strengthening the regulation on e-cigarettes. China adopts various tobacco control measures for e-cigarettes and cigarettes.

CONCLUSIONS

China gained certain degrees of progress on tobacco control by regulating e-cigarettes and adopting measures required by the WHO FCTC. However, tobacco monopoly hinders the full realization of tobacco control goals, which necessitates the National Health Commission to assume its responsibility for the complete implementation of the WHO FCTC.

IMPLICATIONS

This study presents a critical review of the development of e-cigarette regulation in China by reviewing relevant policy documents and analyzing tobacco control measures. It recognizes the degrees of progress of tobacco control measures and highlights tobacco monopoly as a significant hindrance of the full implementation of the WHO FCTC. Furthermore, empirical studies are required on the enforcement of tobacco control measures in China.

Association between Tobacco Industry Interference Index (TIII) and MPOWER measures and adult daily smoking prevalence rate in 30 countries

BACKGROUND

This study aimed to investigate the impact of tobacco industry interference on the implementation and management of tobacco control and the tobacco epidemic using the Tobacco Industry Interference Index (TIII) and MPOWER-a package of measures for tobacco control-and adult daily smoking prevalence in 30 countries.

METHODS

The TIII was extracted from the Global Tobacco Industry Interference Index 2019 and Global Center for Good Governance in Tobacco Control (GGTC). MPOWER measures and adult daily smoking prevalence rate were extracted from the World Health Organization (WHO) report on the global tobacco epidemic in 2021. We assessed the ecological cross-lagged association between TIII and MPOWER scores and between TIII and age-standardized prevalence rates for adult daily tobacco users.

RESULTS

Tobacco industry interference was inversely correlated with a country's package of tobacco control measures (β = -0.088, P = 0.035). The TIII was correlated with weaker warnings about the dangers of tobacco (β = -0.016, P = 0.078) and lack of enforcement of bans on tobacco advertising promotion and sponsorship (β = -0.023, P = 0.026). In turn, the higher the TIII, the higher the age-standardized prevalence of adult daily tobacco smokers for both sexes (β = 0.170, P = 0.036). Adult daily smoking prevalence in males (β = 0.417, P = 0.004) was higher in countries where the tobacco industry received incentives that benefited its business.

CONCLUSION

Where the interference of the tobacco industries was high, national compliance with the Framework Convention on Tobacco Control (FCTC) was lower, and the prevalence of adult daily smokers higher. National governments and global society must work together to minimize the tobacco industry's efforts to interfere with tobacco control policies.

The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies

Background

Many countries have started pursuing tobacco ‘endgame’ goals of creating a ‘tobacco-free’ country by a certain date. Researchers have presented models to attain this goal, including shifting the supply of tobacco to a monopoly-oriented endgame model (MOEM), wherein a state-owned entity controls the supply and distribution of tobacco products. Although not designed to end tobacco use, the Regie in Lebanon exhibits some of the key features identified in MOEM and hence can serve as a practical example from which to draw lessons.

Methods

We comprehensively review previous literature exploring tobacco endgame proposals featuring a MOEM. We distil these propositions into core themes shared between them to guide a deductive analysis of the operations and actions of the Regie to investigate how it aligns (or does not) with the features of the MOEM.

Results

Analysing the endgame proposals featuring MOEM, we generated two main themes: the governance of the organisation; and its operational remit. In line with these themes, the investigation of the Regie led to several reflections on the endgame literature itself, including that it: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like Transnational Tobacco Companies (TTC); (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain.

Conclusion

The implementation of tobacco endgame strategies of any type is now closer than ever. Using the Regie as a practical example allows us to effectively revisit both the potential and the pitfalls of endgame strategies aiming to introduce some form of monopoly and requires a focus on: (i) establishing appropriate governance structures for the organisation; and (ii) adjusting the financial incentives to supress any motivation for the organisation to expand its tobacco market.

Institutional tensions, corporate social responsibility and district-level governance of tobacco industry interference: analysing challenges in local implementation of Article 5.3 measures in Karnataka, India

INTRODUCTION

Accelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level.

METHODS

Based on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels.

RESULTS

Our analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations.

CONCLUSIONS

Promoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India's national health and economic priorities.

Waterpipe tobacco smoking (WTS) control policies: global analysis of available legislation and equity considerations

INTRODUCTION

The Framework Convention on Tobacco Control (FCTC) offers guidance on evidence-based policies to reduce tobacco consumption and its burden of disease. Recently, it has provided guidance for alternative tobacco products, such as the waterpipe. Waterpipe tobacco smoking (WTS) is prevalent worldwide and policies to address it need to take into consideration its specificities as a mode of smoking. In parallel, a growing body of literature points to the potential of evidence-based tobacco control policies to increase health inequities. This paper updates a previous global review of waterpipe tobacco policies and adds an equity lens to assess their impact on health inequities.

METHODS

We reviewed policies that address WTS in 90 countries, including 10 with state-owned tobacco companies; 47 were included in our final analysis. We relied primarily on the Tobacco-Free Kids organisation's Tobacco Control Laws website, providing access to tobacco control laws globally. We categorised country tobacco policies by the clarity with which they defined and addressed waterpipe tobacco in relation to nine FCTC articles. We used the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital) framework for the equity analysis, by reviewing equity considerations referenced in the policies of each country and including prevalence data disaggregated by equity axis and country where available.

RESULTS

Our results revealed very limited attention to waterpipe policies overall, and to equity in such policies, and highlight the complexity of regulating WTS. We recommend that WTS policies and surveillance centre equity as a goal.

CONCLUSIONS

Our recommendations can inform global policies to reduce WTS and its health consequences equitably across population groups.

Public Health Roles in Addressing Commercial Determinants of Health

The shared challenges posed by the production and distribution of health-harming products have led to growing recognition of the need for policy learning and transfer across problems, populations, and social contexts. The commercial determinants of health (CDoH) can serve as a unifying concept to describe the population health consequences arising from for-profit actors and activities, along with the social structures that sustain them. Strategies to mitigate harms from CDoH have focused on behavioral change, regulation, fiscal policies, consumer and citizen activism, and litigation. While there is evidence of effective measures for each strategy, approaches that combine strategies are generally more impactful. Filling gaps in evidence can inform ways of adapting these strategies to specific populations and social contexts. Overall, CDoH are addressed most effectively not through siloed efforts to reduce consumption of health-harming products, but instead as a set of integrated strategies to reduce exposures to health-harming commercial actors and activities.

Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Tobacco control and prevention efforts in Ethiopia pre- and post-ratification of WHO FCTC: Current challenges and future directions

INTRODUCTION

Being the second most populous African country, Ethiopia represents a huge opportunity for the tobacco industry to recruit new smokers. Ethiopia signed the convention to ratify WHO Framework Convention on Tobacco Control (FCTC) in 2004 and ratified in 2014. We reviewed Ethiopia’s tobacco control legislative history pre- and post-ratification of the WHO FCTC and evaluated the level of compliance of the National Tobacco Control Directive (NTCD) with the WHO FCTC.

METHODS

We reviewed Ethiopia’s tobacco legislative history, the NCTD, the National Tobacco Control Strategic Plan, and tobacco control related media stories from 2009 to 2018. The level of compliance of NTCD with WHO FCTC was compared and qualitatively analysed.

RESULTS

NTCD 2015 is Ethiopia’s first comprehensive tobacco control legislation, which for the most part is WHO FCTC compliant. The legislation prohibits, among other things, sale of flavoured tobacco products including menthol, sale of tobacco products to a person under the age of 18 years and bans all forms of tobacco advertising, promotion, and sponsorship. Yet, the current legislation allows smoking designated rooms in some prohibited places. Although a multi-sectoral National Tobacco Control Committee and a Strategic Plan were developed as per Article 5 of WHO FCTC, activities pertaining to the protection of such tobacco control policies from vested interests of the tobacco industry (WHO FCTC Article 5.3) are not addressed in NTCD 2015.

CONCLUSIONS

Major gaps in the NTCD 2015 such as allowing smoking designated rooms should be addressed in order to stop the tobacco industry from using such loopholes to interfere with national tobacco control policies and/or maintain its tobacco market. Moreover, the tobacco control policies and efforts should be institutionalized across various sectors in order to ensure implementation of the NTCD.

The tobacco endgame: The neglected role of place and environment

An increasing number of countries across the world are planning for the eradication of the tobacco epidemic. The actions necessary to realise this ambition have been termed the tobacco endgame. The focus of this paper is on the intersection between the tobacco endgame with place, a neglected theme in recent academic and policy debates. We begin with an overview of the key themes in the literature on endgame strategies before detailing the international landscape of engame initiatives, paying particular attention to the opportunities and challenges of endgame strategies in low and middle income countries. Finally, we critically assess the current endgame debates and suggest a novel agenda for integrating geographical perspectives into research on the endgame that provides enhanced understanding of the challenges associated with this important global health vision.

'Preparing ourselves to become an international organization': Thailand Tobacco Monopoly's regional and global strategies

The Thailand Tobacco Monopoly (TTM) controlled the country’s tobacco industry from its formation in the 1940s, until the government dropped restrictions on imported cigarettes in the late 1980s in response to pressure from the United States. The TTM has since competed with transnational tobacco companies (TTCs) in a semi-monopoly market in which TTCs have steadily increased their market share. Coupled with a decline in national smoking prevalence, the result of Thailand’s stringent tobacco control agenda, the TTM now accounts for a diminishing share of a contracting market. In response, the monopoly has looked to regional trade liberalisation, and proximity to markets with some of the world’s highest smoking rates to expand its operations. Expansion strategies have gone largely unrealised however, and the TTM effectively remains a domestic operation. Using TTM publications, market and trade reports, industry publications, tobacco industry documents and other resources, this paper analyses TTM expansion strategies, and the limited extent to which they have been achieved. This inability to expand its operations has left the monopoly potentially vulnerable to global strategies of its transnational competitors. This article is part of the special issue ‘The Emergence of Asian Tobacco Companies: Implications for Global Health Governance’.

Requirements of health policy and services journals for authors to disclose financial and non-financial conflicts of interest: a cross-sectional study

BACKGROUND

The requirements of the health policy and services journals for authors to report their financial and non-financial conflicts of interest (COI) are unclear. The present article aims to assess the requirements of health policy and services journals for authors to disclose their financial and non-financial COIs.

METHODS

This is a cross-sectional study of journals listed by the Web of Science under the category of 'Health Policy and Services'. We reviewed the 'Instructions for Authors' on the journals' websites and then simulated the submission of a manuscript to obtain any additional relevant information made available during that step. We abstracted data in duplicate and independently using a standardised form.

RESULTS

Out of 72 eligible journals, 67 (93%) had a COI policy. A minority of policies described how the disclosed COIs of authors would impact the editorial process (34%). None of the policies had clear-cut criteria for rejection based on the content of the disclosure. Approximately a fifth of policies (21%) explicitly stated that inaccurate or incomplete disclosures might lead to manuscript rejection or retraction. No policy described whether the journal would verify the accuracy or completeness of authors' disclosed COIs. Most journals' policies (93%) required the disclosure of at least one form of financial COI. While the majority asked for specification of source of payment (71%), a minority asked for the amount (18%). Overall, 81% of policies explicitly required disclosure of non-financial COIs.

CONCLUSION

A majority of health policy and services journal policies required the disclosure of authors' financial and non-financial COIs, but few required details on disclosed COIs. Health policy journals should provide specific definitions and instructions for disclosing non-financial COIs. A framework providing clear typology and operational definitions of the different types of COIs will facilitate both their disclosure by authors and reviewers and their assessment and management by the editorial team and the readers.

The globalisation strategies of five Asian tobacco companies: a comparative analysis and implications for global health governance

The global tobacco industry, from the 1960s to mid 1990s, saw consolidation and eventual domination by a small number of transnational tobacco companies (TTC). This paper draws together comparative analysis of five case studies in the special issue on 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.' The cases suggest that tobacco industry globalisation is undergoing a new phase, beginning in the late 1990s, with the adoption of global business strategies by five Asian companies. The strategies were prompted foremost by external factors, notably market liberalisation, competition from TTCs and declining domestic markets. State protection and promotion enabled the industries in Japan, South Korea and China to rationalise their operations ahead of foreign market expansion. The TTM and TTL will likely remain domestic or perhaps regional companies, JTI and KT&G have achieved TTC status, and the CNTC is poised to dwarf all existing companies. This global expansion of Asian tobacco companies will increase competition which, in turn, will intensify marketing, exert downward price pressures along the global value chain, and encourage product innovation. Global tobacco control requires fuller understanding of these emerging changes and the regulatory challenges posed by ongoing globalisation.

The globalisation strategies of five Asian tobacco companies: An analytical framework

With 30% of the world’s smokers, two million deaths annually from tobacco use, and rising levels of tobacco consumption, the Asian region is recognised as central to the future of global tobacco control. There is less understanding, however, of how Asian tobacco companies with regional and global aspirations are contributing to the global burden of tobacco-related disease and death. This introductory article sets out the background and rationale for this special issue on ‘The Emergence of Asian Tobacco Companies: Implications for Global Health Governance’. The article discusses the core questions to be addressed and presents an analytical framework for assessing the globalisation strategies of Asian tobacco firms. The article also discusses the selection of the five case studies, namely as independent companies in Asia which have demonstrated concerted ambitions to be a major player in the world market.

A Public Health Framework for Legalized Retail Marijuana Based on the US Experience: Avoiding a New Tobacco Industry

Rachel Barry and Stanton Glantz argue that a public health framework that prioritizes public health over business interests should be used by US states and countries that legalize retail marijuana.

Tobacco industry globalization and global health governance: towards an interdisciplinary research agenda

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century, prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article, we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses. This article is published as part of a thematic collection dedicated to global governance.