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

Response of legal and illegal cigarette prices to a tax increase in Ethiopia

BACKGROUND

In 2020, Ethiopia passed a landmark tax proclamation implementing an evidence-based mixed excise system aimed at curbing tobacco use. This study evaluates the impact of the tax increase of more than 600% on both legal and illegal cigarette prices in order to gauge the impact of the tax reform in the presence of a sizeable illicit cigarette market.

METHODS

Data on 1774 cigarette prices were obtained from retailers during Empty Cigarette Pack Surveys in the capital and major regional cities conducted in 2018 and 2022. Packs were categorised as 'legal' or 'illicit' using criteria from the tobacco control directives. Descriptive and regression analyses were used to study the cigarette price changes during the period of 2018-2022, capturing the impact of the 2020 tax increase.

RESULT

Prices of both legal and illegal cigarettes increased in response to the tax increase. In 2018, the stick prices ranged from ETB0.88 (Ethiopian birr) to ETB5.00 for legal cigarettes while they ranged from ETB0.75 to ETB3.25 for illegal ones. In 2022, a legal stick sold for ETB01.50-ETB2.73 and an illegal stick for ETB1.92-ETB8.00. The average real price of legal and illegal brands increased by 18% and 37%, respectively. The multivariate analysis confirms that prices of illicit cigarettes grew faster compared with the legal ones. By 2022, illicit brands were on average more expensive compared with their legal counterparts. This result is statistically significant at p<0.01.

CONCLUSION

The prices of both legal and illegal cigarettes increased following the 2020 tax increase, with the average real cigarette price increasing by 24%. As a result, the tax increase likely had a positive impact on public health despite a sizeable illicit cigarette market.

Tobacco policy (in)coherence in Mozambique: an examination of national and subnational stakeholder perspectives

Mozambique ranks fifth on the list of tobacco producing countries in Africa, while also being a Party to the WHO Framework Convention on Tobacco Control (FCTC). Tobacco farming is regarded by some governments as a strategic economic commodity for export and remains deeply entrenched within Mozambique's political and economic landscape. This study uses a qualitative description methodology to identify tensions, conflicts and alignment or misalignment in policy on tobacco across government sectors and levels in Mozambique. We conducted semi-structured qualitative interviews with 33 key informants from sectors across national and subnational levels including health, agriculture, economic and commercial sectors, as well as non-state actors from civil society organizations, the tobacco industry, farmers unions and associations and individual farmers. Incoherence was present across sectoral mandates, perspectives on industry's presence in the country and regions and between FCTC provisions and informant perceptions of tobacco production as a development strategy. Despite tobacco being viewed as an important economic commodity by many informants, there was also widespread dissatisfaction with tobacco from both farmers and some government officials. There were indications of an openness to shifting to a policy that emphasizes alternatives to tobacco growing. The findings also illustrate where points of convergence exist across sectors and where opportunities for aligning tobacco policy with the provisions of the FCTC can occur.

Addressing tobacco industry influence in tobacco-growing countries

Protecting policy-making from tobacco industry influence is central to effective tobacco control governance. The inclusion of industry actors as stakeholders in policy processes remains a crucial avenue to corporate influence. This influence is reinforced by the idea that the tobacco industry is a legitimate partner to government in regulatory governance. Addressing the influence of the tobacco industry demands a focus on the government institutions that formalize relationships between industry and policy-makers. Industry involvement in government institutions is particularly relevant in tobacco-growing countries, where sectors of government actively support tobacco as an economic commodity. In this paper, we discuss how controlling tobacco industry influence requires unique consideration in tobacco-growing countries. In these countries, there is a diverse array of companies that support tobacco production, including suppliers of seeds, equipment and chemicals, as well as transportation, leaf buying and processing, and manufacturing companies. The range of companies that operate in these contexts is particular and so is their engagement within political institutions. For governments wanting to support alternatives to tobacco growing (Article 17 of the Framework Convention for Tobacco Control), we illustrate how implementing Article 5.3, aimed at protecting tobacco control policies from tobacco industry interference, is fundamental in these countries. Integrating Article 5.3 with Article 17 will (i) strengthen policy coherence, ensuring that alternative livelihood policies are not undermined by tobacco industry interference; (ii) foster cross-sector collaboration addressing both tobacco industry interference and livelihood development; and (iii) enhance accountability and transparency in tobacco control efforts.

Framing, moral foundations and health taxes: interpretive analysis of Ethiopia's tobacco excise tax policy passage

BACKGROUND

In 2019-2020, the Ethiopian government ratified a suite of legislative measures that includes levying a tax on tobacco products. This study aims to examine stakeholders' involvement, position, power and perception regarding the Ethiopian Food and Drug Authority (EFDA) bill (Proclamation No.1112/2019). This includes their meaning-making and interaction with each other during the bill's formulation, adoption and implementation stages.

METHODS

We employed a mixed-methods design drawing on three sources of data: (1) policy documents and media articles from government and/or civil society groups (n=27), (2) audio and video transcripts of parliamentary debates and (3) qualitative stakeholder interviews.

RESULTS

Policy actors in both the public health camp and tobacco industry employed several framing moves, engaged in distinctive patterns of moral rhetoric, and strategically invoked moral languages to galvanise support for their policy objectives. Central to this framing debate are issues of public health and the danger of tobacco, and the protection of 'the economy and personal freedom'. The public health camp's arguments and persuasiveness-which led to the passage of the EFDA bill-centred around discrediting tobacco industry's cost-benefit assessments through frame disconnection, or by polarising their own position that the financial, psychological and lost productivity costs incurred by tobacco use outweighs any tax revenue.

CONCLUSIONS

A successful cultivation of an epistemic community and engagement of policy entrepreneurs-both from government agencies and civil society organisations-was critical in creating a united front and a compelling affirmative policy narrative, thereby influence excise tax policy outcomes.

Tobacco industry corporate social responsibility activities and other interference after ratification of a strong tobacco law in Ethiopia

BACKGROUND

Since strict new tobacco control laws were introduced in 2019 and 2020, the National Tobacco Enterprise (NTE), the main manufacturer and distributor of cigarettes in Ethiopia, strategically engaged in corporate social responsibility (CSR) activities and other tactics to interfere in tobacco control policymaking. This study systematically identified and reviewed tobacco industry activities that undermine Ethiopia's strict new tobacco control laws.

METHODS

We collated, reviewed and analysed evidence on tobacco industry CSR activities from February 2019 to November 2022 in Ethiopia, including newspapers, organisational websites, social media and government documents related to tobacco industry activities, contract agreements and other policy interference attempts.

RESULTS

NTE's CSR activities included: (1) Funding educational programmes (eg, postgraduate scholarships); (2) Community service (eg, donating COVID-19 prevention materials, providing water, sanitation and hygiene supplies); and (3) Supporting government programmes (eg, greening initiatives and training programmes). NTE facilitated CSR activities via a contract agreement with the Ethiopian government that was created when Japan Tobacco International purchased the Government's majority share in NTE. NTE subsequently partnered with the Japanese Embassy in Addis Ababa and private law firms on CSR activities. The tobacco control community stopped NTE distributing free COVID-19 prevention products in Addis Ababa but had limited impact on other identified breaches of laws prohibiting tobacco advertising promotion and sponsorship.

CONCLUSION

The new laws have not stopped NTE using multiple CSR activities to interfere in tobacco control policy. Regular monitoring of tobacco industry CSR activities to identify potential breaches is recommended. Moreover, the Ethiopian government should revise its contractual agreement with NTE to end NTE's participation in law-making processes and partnerships on illicit tobacco control.

Awareness, attitudes and practices relating to Article 5.3 of the WHO Framework Convention on Tobacco Control among members of tobacco control committees in a southern Indian state

BACKGROUND AND OBJECTIVES

The tobacco industry (TI) has undermined tobacco control policy for decades. The WHO Framework Convention on Tobacco Control Article 5.3 implementation guidelines provide guidance for preventing TI interference. Government officials responsible for policy implementation must understand these guidelines to manage TI tactics. This study assessed awareness, attitudes and practices of Article 5.3 guidelines among members of District Level Coordination Committees (DLCC) in Karnataka mandated with overseeing tobacco control activity.

METHOD

A semistructured questionnaire survey of awareness, attitudes and adherence to Article 5.3 guidelines among 102 DLCC members carried out between January and July 2019.

RESULT

Responses were received from 82 members, comprising 51 (62%) from health and 31 (38%) from non-health departments. Our study demonstrates a lack of understanding of Article 5.3 and its guidelines, even among those actively involved in tobacco control at the district level. Nearly 80% of respondents were aware that corporate social responsibility (CSR) by tobacco companies is an indirect form of promoting tobacco. However, 44% of members felt that CSR funding from the TI should be used to combat tobacco-related harm. A higher proportion (12%) of health respondents agreed that subsidies should be provided to tobacco agriculture compared with non-health (3%).

CONCLUSION

Awareness of international guidance designed to prevent the TI influence on health policy among policymakers in this Indian state is low. Respondents from non-health departments were less aware of TI CSR. Those in health departments were more receptive towards taking a TI role in the future .

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis

BACKGROUND

The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs.

METHODS

We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs.

RESULTS

We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process.

CONCLUSIONS

The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42020191541.

Advancing whole-of-government approaches to tobacco control: Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

INTRODUCTION

Despite an extensive evidence base on the diverse economic, environmental and social benefits of tobacco control, difficulties in establishing coordinated national approaches remain a defining challenge for Framework Convention on Tobacco Control (FCTC) implementation. Minimising tobacco industry interference is seen as key to effective coordination, and this paper analyses implementation of Article 5.3 guidelines, exploring implications for whole-of-government approaches to tobacco control in Bangladesh, Ethiopia, India and Uganda.

METHODS

Based on 131 semistructured interviews with government officials and other key stakeholders, we explore barriers and facilitators for promoting: (1) horizontal coordination across health and other policy spheres, and (2) vertical coordination across national and subnational governments on Article 5.3 implementation.

RESULTS

Our analysis identifies common barriers to coordination across diverse geographical contexts and varying approaches to implementation. They highlight broadly shared experiences of limited understanding and engagement beyond health agencies; restricted responsibility and uncertainty amid conflicting mandates; tensions with wider governance practices and norms; limited capacity and authority of coordination mechanisms; and obstacles to vertical coordination across local, state and national governments. Interview data also indicate important opportunities to advance coordination across sectors and government levels, with Article 5.3 measures capable of informing changes in practices, building support in other sectors, allowing for 'bottom-up' innovation and being shaped by engagement with civil society.

CONCLUSION

Supporting effective implementation of Article 5.3 is key to advancing multisectoral approaches to FCTC implementation and tobacco control's contributions to global health and sustainable development.

Norms, rules and policy tools: understanding Article 5.3 as an instrument of tobacco control governance

INTRODUCTION

Article 5.3 of the WHO Framework Convention on Tobacco Control, elaborated via its implementation guidelines, can be understood as a policy instrument comprising norms, rules and policy tools designed to shape practices of policy making and minimise tobacco industry interference.

METHODS

This qualitative research is based on in-depth interviews with officials from diverse government sectors and non-governmental organisations across countries (Ethiopia, India, Uganda) that have adopted measures to implement Article 5.3.

RESULTS

The data highlight varied perceptions and knowledge of Article 5.3 norms between health and non-health sectors. Health officials typically link its core norm of a fundamental conflict between public health and industry interests to the governance norm of protecting public health policies from industry interference. While officials in sectors beyond health broadly endorsed this core norm, they exhibited more limited awareness of Article 5.3 and its model of governance. The results examine how rules to implement Article 5.3 have been codified, but identify the absence of policy tools necessary to operationalise rules and norms. This limitation, alongside restricted awareness beyond health departments, suggests that political commitments to implement Article 5.3 will have limited impact on practices of stakeholder consultation and policy engagement with the tobacco industry.

CONCLUSION

Conceptualising Article 5.3 as a policy instrument helps to explain how its rules and policy tools interact with each other and with broader governance processes. This framework has the potential to enhance understanding of Article 5.3 and help identify opportunities and constraints in its implementation.