Supporting Pacific Island countries to strengthen their resistance to tobacco industry interference in tobacco control: a case study of Papua New Guinea and Solomon Islands

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The challenges in protecting public health interests in multisectoral governance in the context of small island developing states: the case of tobacco control in Fiji and Vanuatu

BACKGROUND

The commercial determinants of health (CDoH) drive the rise of NCDs globally, and their regulation requires multisectoral governance. Despite existing recommendations to strengthen institutional structures, protecting public health interests can be challenging amidst industry interference and conflicting policy priorities, particularly in low and middle-income countries (LMICs) where the need for rapid economic development is pronounced. Small island developing states (SIDS) face even more challenges in regulating CDoH because their unique socioeconomic, political, and geographic vulnerabilities may weaken institutional conditions that could aid health sector actors in protecting health interests. This study aims to explore the institutional conditions that shape health sector actors' capability to protect public health interests in tobacco governance in Fiji and Vanuatu.

METHODS

We employed a qualitative, exploratory case study design. We applied the administrative process theory to inform data collection and analysis. Seventy interviews were completed in Fiji and Vanuatu from 2018 to 2019.

RESULTS

The findings show that the protection of health interests in tobacco governance were not supported by the institutional conditions in Fiji and Vanuatu. While the policy processes formally ensured a level playing field between actors, policies were often developed through informal mechanisms, and the safeguards to protect public interests from vested private interests were not implemented adequately. SIDS vulnerabilities and weak regulation of political parties contributed to the politicisation of government in both states, resulting in high-level government officials' questionable commitment to protect public health interests. The system of checks and balances usually embedded into democratic governments appeared to be muted, and policymakers had limited bureaucratic autonomy to elevate health interests in multisectoral policymaking amidst high-level government officials' frequent rotation. Finally, capacity constraints aggravated by SIDS vulnerabilities negatively impacted health sector actors' capability to analyse policy alternatives.

CONCLUSIONS

Health sector actors in Fiji and Vanuatu were not supported by institutional conditions that could help them protect public health interests in multisectoral governance to regulate CDoH originating from the tobacco industry. Institutional conditions in these states were shaped by SIDS vulnerabilities but could be improved by targeted capacity building, governance and political system strengthening.

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.

Authority in tobacco control in Pacific Small Island Developing States: a qualitative study of multisectoral tobacco governance in Fiji and Vanuatu

OBJECTIVE

Small Island Developing States (SIDS) struggle with implementing multisectoral tobacco control measures, and health sector actors often lack capacity to forge multisectoral commitment. This study aims to explore the sources and dynamics of authority that can enable multisectoral collaboration despite the divergence of policy agendas in tobacco control.

METHODS

We applied a qualitative, explorative case study design, with data collection and analysis guided by an analytical framework that identifies sources and dynamics of authority. Seventy interviews were conducted in Fiji and Vanuatu between 2018 and 2019.

RESULTS

The key features shaping multisectoral coordination for tobacco control in Fiji and Vanuatu are the expert, institutional, capacity-based and legal authority that state and non-state actors have in tobacco governance. The amount of authority actors can secure from these sources was shown to be influenced by their performance (perceived or real), the discourse around tobacco control, the existing legal tools and their strategic alliances. SIDS vulnerabilities, arising from small size, isolation and developing economies, facilitate an economic growth discourse that reduces health sector actors' authority and empowers protobacco actors to drive tobacco governance.

CONCLUSIONS

Our results highlight the need for terms of engagement with the tobacco industry to enable governments to implement multisectoral tobacco control measures. Expanding assistance on tobacco control among government and civil society actors and increasing messaging about the impact of economic, trade and agricultural practices on health are essential to help SIDS implement the Framework Convention on Tobacco Control.

Challenges of conflict of interest, coordination and collaboration in small island contexts: towards effective tobacco control governance in UK Overseas Territories

INTRODUCTION

The UK Overseas Territories (UKOTs) are semi-autonomous jurisdictions that face distinctive challenges in implementing tobacco control and protecting policy from industry influence. They are not eligible to become independent parties of the WHO Framework Convention on Tobacco Control (FCTC), although they can apply for treaty extension under the UK's ratification. This study explores the relevance of the FCTC-particularly Article 5.3-for tobacco control governance across a sample of UKOTs.

METHODS

From March to May 2019, we interviewed 32 stakeholders across four territories (Anguilla, Bermuda, Cayman Islands, St Helena) at diverse stages in implementing key FCTC measures. Thematic qualitative analysis explored awareness and perceptions in relation to tobacco control.

RESULTS

Interviewees' accounts highlight the complexity of protecting health policy from industry influence in a context where the 'tobacco industry' covers a diverse range of actors. Despite not being formally covered by the FCTC, several health officials spoke about the strategic value of invoking Article 5.3 in the context of tensions with economic priorities. Nevertheless, effective tobacco control governance is complicated by territories' reliance on local businesses-including tourism-and close social connections that occasionally blur the lines between private and public spheres.

CONCLUSIONS

The UKOTs share many characteristics with other small island jurisdictions, creating distinctive challenges for advancing tobacco control and protecting policy from industry interference. Despite their complex status in relation to WHO and its architecture, these territories benefit from the norms embedded in the FCTC and the systems that support its implementation.

Getting there together: highlights, challenges and opportunities for tobacco control in the Oceania region

BACKGROUND

The paper focuses on the geographical region of Oceania. We highlight the tobacco control leadership demonstrated in this region and describe the challenges and opportunities to achieving country-specific smoke-free goals.

RESULTS

Significant achievements include smoke-free nation goals, world-leading initiatives such as plain packaging, and a bold plan by New Zealand to reduce the retail availability of smoked tobacco products and remove virtually all the nicotine from cigarettes and rolling tobacco. There are significant challenges and opportunities before reaching smoke-free status including implementation pathways requiring strong governance and leadership and compliance monitoring and enforcement.

CONCLUSIONS

We conclude that achieving a smoke-free Oceania is possible through already existing bold country and regional smoke-free goals, excellent tobacco control leadership, experience and resources, and an understanding of how to work collectively. However, a commitment to focus tobacco control efforts regionally is required to achieve a smoke-free Oceania together.

Prevalence and trends in tobacco use among adolescents aged 13-15 years in 143 countries, 1999-2018: findings from the Global Youth Tobacco Surveys

BACKGROUND

Tobacco use is a leading preventable cause of morbidity and mortality worldwide. Little is known about recent prevalence and trends in tobacco use among adolescents globally. We aimed to assess the recent global prevalence of tobacco use in young adolescents and the secular trends in prevalence between 1999 and 2018.

METHODS

We used the most recent Global Youth Tobacco Surveys data on adolescents aged 13-15 years from 143 countries or territories that had done at least one survey between Jan 1, 2010, and Dec 31, 2018, to assess the recent prevalence of tobacco use; and data from 140 countries that had done two or more surveys between Jan 1, 1999, and Dec 31, 2018, to assess the trends in the prevalence of tobacco use.

FINDINGS

530 234 adolescents were included from the 143 countries that had done at least one survey between 2010 and 2018. 1 192 312 adolescents were included from the 140 countries that had done two or more surveys between 1999 and 2018. The most recent global prevalence of cigarette smoking was 11·3% (95% CI 10·3-12·3) in boys and 6·1% (5·6-6·6) in girls, based on cigarette smoking on at least 1 day during the past 30 days, 6·0% (5·5-6·6) and 2·6% (2·4-2·9) based on smoking on at least 3 days, and 4·2% (3·8-4·6) and 1·6% (1·4-1·8) based on smoking on at least 6 days. The most recent prevalence of the use of tobacco products other than cigarettes (eg, chewing tobacco, snuff, dip, cigars, cigarillos, pipe, electronic cigarettes) on at least 1 day during the past 30 days was 11·2% (9·9-12·6) in boys and 7·0% (6·4-7·7) in girls. The most recent prevalence of any tobacco use on at least 1 day during the past 30 days was 17·9% (16·1-19·6) in boys and 11·5% (10·5-12·4) in girls. The prevalence of cigarette smoking on at least 1 day during the past 30 days decreased between the first and last surveys in 80 (57·1%) of 140 countries, was unchanged in 39 countries (27·9%), and increased in 21 countries (15·0%). However, the prevalence of the use of tobacco products other than cigarettes was unchanged or increased in 81 (59·1%) of 137 countries.

INTERPRETATION

The global prevalence of tobacco use among adolescents aged 13-15 years was substantial. Although the prevalence of cigarette smoking decreased over time in the majority of countries, the prevalence of the use of other tobacco products increased or did not change in the majority of countries during the past two decades. These findings re-emphasise the need to strengthen tobacco control efforts among young adolescents globally.

FUNDING

Shandong University.

Tobacco Smoking in Islands of the Pacific Region, 2001-2013

We provide an overview of tobacco smoking patterns in Pacific island countries and territories to facilitate monitoring progress toward the goal of a Tobacco-Free Pacific by 2025. We examined data from 4 surveys conducted in the region between 2001 and 2013, including the STEPwise approach to surveillance for adults (25–64 years); the Global School-Based Student Health Survey and the Global Youth Tobacco Survey (students 13–15 years); and the Youth Risk Behavior Surveillance System (grade 9–12 students) in United States affiliated Pacific Islands (USAPIs). Adult smoking prevalence ranged from less than 5% of women in Vanuatu to almost 75% of men in Kiribati. Smoking prevalence among students (13–15 years) ranged between 5.6% and 52.1%. There were declines in smoking among youths in many USAPIs. To achieve the tobacco-free goal and reduce disease burden, accelerated action is needed to align national legislation with international agreements and build capacity for tobacco control at all levels.

Adolescents Perceptions of Pro- and Antitobacco Imagery and Marketing: Qualitative Study of Students from Suva, Fiji

BACKGROUND

Many studies examining smoking uptake among young people in the Pacific have not included their exposure to tobacco control promotions in the media in their assessment. This study examines how Fijian students view tobacco and tobacco-related media depictions to gain insight into both drivers of smoking uptake and potential directions for prevention interventions.

METHODS

A sample of thirty Fijian students (15 male and 15 female) aged 14-17 years, was recruited from a Suva school between September and October 2013 and participated in a one-to-one in-depth interview about their views on tobacco use, media consumption patterns and preferences and awareness of tobacco use in media.

RESULTS

Despite radical developments in access to media, television remains the most popular. Yet, the majority of participants were unaware of any protobacco imagery on television or other entertainment media. Tobacco-related imagery was more likely to be seen in connection with point of sale advertising and branding. The advertising potential of the shop counter was acutely apparent to some participants and this space was considered highly influential.

CONCLUSIONS

Despite the fact that the recently introduced graphic health warnings were generally well received, more can be done to extend the use of media for tobacco control benefits in Fiji.

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.