Success counteracting tobacco company interference in Thailand: an example of FCTC implementation for low- and middle-income countries

Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh

BACKGROUND

In Bangladesh, the 2013 Amendment of the Tobacco Control Act made graphic health warnings (GHWs) on the upper 50% of all tobacco packs obligatory. However, at the time of writing (May 2022), GHWs are still being printed on the lower 50% of packs. This paper seeks to explore how the tobacco industry undermined the development and implementation of GHWs in Bangladesh, a country known for a high level of tobacco industry interference (TII) that has rarely been examined in the peer-reviewed literature.

METHODS

Analysis of print and electronic media articles and documents.

RESULTS

Cigarette companies actively opposed GHWs, while bidi companies did not. The primary strategy used to influence the formulation and delay the implementation of GHWs was direct lobbying by the Bangladesh Cigarette Manufacturers' Association and British American Tobacco Bangladesh. Their arguments stressed the economic benefits of tobacco to Bangladesh and sought to create confusion about the impact of GHWs, for example, claiming that GHWs would obscure tax banderols, thus threatening revenue collection. They also claimed technical barriers to implementation-that new machinery would be needed-leading to delays. Tensions between government bodies were identified, one of which (National Board of Revenue)-seemingly close to cigarette companies and representing their arguments-sought to influence others to adopt industry-preferred positions. Finally, although tobacco control advocates were partially successful in counteracting TII, one self-proclaimed tobacco control group, whose nature remains unclear, threatened the otherwise united approach.

CONCLUSIONS

The strategies cigarette companies used closely resemble key techniques from the well-evidenced tobacco industry playbook. The study underlines the importance of continuing monitoring and investigations into industry conduct and suspicious actors. Prioritising the implementation of WHO Framework Convention on Tobacco Control Article 5.3 is crucial for advancing tobacco control, particularly in places like Bangladesh, where close government-industry links exist.

Projecting the impact of implementation of WHO MPOWER measures on smoking prevalence and mortality in Japan

OBJECTIVE

This study aimed to quantify the long-term impact of implementing the WHO Framework Convention on Tobacco Control (FCTC) compliant tobacco control measures, MPOWER, on smoking prevalence and mortality in men and women aged ≥20 years in Japan.

DESIGN

A Stock-and-Flow simulation model was used to project smoking prevalence and mortality from 2018 to 2050 under eight different scenarios: (1) maintaining the 2018 status quo, (2) implementation of smoke-free policies, (3) tobacco use cessation programmes, (4-5) health warning about the dangers of tobacco (labels, mass media), (6) enforcement of tobacco advertising bans or (7) tobacco taxation at the highest recommended level and (8) all these interventions combined.

RESULTS

Under the status quo, the smoking prevalence in Japan will decrease from 29.6% to 15.5% in men and 8.3% to 4.7% in women by 2050. Full implementation of MPOWER will accelerate this trend, dropping the prevalence to 10.6% in men and 3.2% in women, and save nearly a quarter million deaths by 2050. This reduction implies that Japan will only attain the current national target of 12% overall smoking prevalence in 2033, 8 years earlier than it would with the status quo (in 2041), a significant delay from the national government's 2022 deadline.

CONCLUSIONS

To bring forward the elimination of tobacco smoking and substantially reduce smoking-related deaths, the government of Japan should fulfil its commitment to the FCTC and adopt stringent tobacco control measures delineated by MPOWER and beyond.

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Critical analysis of tobacco taxation policies in Pakistan after two decades of FCTC: Policy gaps and lessons for low- and middle-income countries

INTRODUCTION

Tobacco taxation remains a poorly used intervention to control tobacco use in many low- and middle-income countries (LMICs) including Pakistan even after two decades of FCTC adoption. This study identifies gaps and implementation challenges in the current Tobacco Taxation and Pricing Policies (TTPP) in Pakistan, and highlights key policy implications and lessons for LMICs to strengthen tobacco control measures.

METHODS

We used qualitative document analysis to examine the policy documents to assess the TTPP against the WHO Framework Convention on Tobacco Control (FCTC) guidelines for the implementation of Article 6 of the FCTC. In addition, we used secondary data on tobacco tax and prices to assess the impact of TTPP on tobacco affordability in the country.

RESULTS

Although Pakistan taxes raw tobacco, cigarettes and other tobacco products (cigarillos, cigars, cheroots), the existing TTPP falls below the WHO FCTC requirements of: uniform tax level, simple tax structure and 70% share of excise tax in the price of a product's pack; among others. There are also multiple issues in tobacco tax administration such as lack of monitoring. This is leading to the availability of highly affordable tobacco products in the country.

CONCLUSIONS

Pakistan does not have a clear strategy on using tobacco taxation and prices as a public health tool in the country. Existing TTPP face dual issues of flawed structure and poor administration translating into highly affordable tobacco products and low revenues in the country. There is a need to introduce multisectoral tobacco control policies in countries like Pakistan in the context of the tobacco sector political economy.

Perception of and legal compliance with the law prohibiting cigarette sales to minors in Thailand following the raising of the minimum selling age to 20 years: a cross-sectional survey

OBJECTIVES

The minimum age for cigarette sales in Thailand was increased from 18 to 20 years, as stipulated in the Tobacco Products Control Act B.E. 2017. This study investigated tobacco retailers' perceptions, cigarette sales behaviour and other factors relevant to selling cigarettes to people younger than 20 years in areas surrounding schools in Thailand.

DESIGN

Cross-sectional survey.

SETTING

Tobacco shops within a radius of 500 m of secondary schools across four regions of Thailand. Data collection took place between May and August 2019.

PARTICIPANTS

1440 tobacco retailers (grocery or convenience stores) were sampled via a stratified, two-stage cluster sampling method. 1021 retailers completed the self-administered questionnaire.

OUTCOME MEASURES

Tobacco sales to people younger than 20 years.

RESULTS

The prevalence of the retailers' cigarette sales to youth younger than 20 years was 38.20% (95% CI 35.2% to 41.3%). Multivariable logistic regression analysis revealed associations with sale of single cigarettes (adjusted OR (AOR) 23.14, 95% CI 15.13 to 35.39), self-service sale of cigarettes (4.21, 2.59 to 6.86) and display of cigarettes at the point of sale (2.39, 1.47 to 3.89). Cigarette sales to underage youth were higher among retailers located in the northeast region (AOR 2.09, 95% CI 1.20 to 3.64) and among those who did not perceive the prosecution of violators in the past year (1.85, 1.16 to 2.96).

CONCLUSION

A large percentage of cigarette retailers violated the laws related to underage cigarette sales. Measures to minimise retailers' legally non-compliant sales behaviours should be implemented along with improved legal enforcement.

Advocacy counterstrategies to tobacco industry interference in policymaking: a scoping review of peer-reviewed literature

BACKGROUND

There has been remarkable tobacco control progress in many places around the globe. Tobacco industry interference (TII) has been identified as the most significant barrier to further implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Civil society has been recognised as a key actor in countering TII. While TII has been extensively studied for several decades now, there is little research that focuses on counteractions to limit it and their effectiveness to do so. This scoping review seeks to map the peer-reviewed literature on civil society's activities of countering TII in policymaking to identify common counterstrategies and assess their effectiveness.

METHODS

Data sources: We searched Embase, IBSS, JSTOR, PubMed, Science Direct, Scopus and Web of Science using the following terms: ("Tobacco industry" OR "Tobacco compan*") AND. ("corporate political activity" OR "CPA" OR "lobbying" OR "interference") AND ("advoca*" OR "counter*" OR "activi*"), without time or language restrictions.

STUDY SELECTION

Our selection criteria included peer-reviewed studies that were written in English, German, or Spanish that drew on primary data and/or legal and policy documents and reported at least one specific example of civil society members or organisations countering tobacco industry action-based strategies.

DATA EXTRACTION

Advocates' counterstrategies were analysed inductively and countered industry strategies were analysed using the Policy Dystopia Model (PDM). Perceptions of effectiveness of countering attempts were analysed descriptively.

RESULTS

We found five common counterstrategies among 30 included papers covering five WHO regions; 1. Exposing industry conduct and false claims; 2. Accessing decision-makers; 3. Generating and using evidence; 4. Filing a complaint or taking legal action; 5. Mobilising coalition and potential supporters. These counterstrategies were used to work against a wide range of industry strategies, which are captured by five action-based strategies described in the PDM (Coalition Management, Information Management, Direct Access and Influence, Litigation, Reputation Management). While some studies reported the outcome of the countering activities, their impact remained largely underexplored.

CONCLUSION

The review shows that peer-reviewed literature documenting how civil society actors counter TII is scarce. It suggests that advocates employ a range of strategies to counter TII in its different forms and use them flexibly. More work is needed to better understand the effects of their actions. This could stimulate discussions about, and facilitate learning from, past experiences and help to further enhance advocates' capacity.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh

OBJECTIVES

This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs).

METHODS

We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections.

RESULTS

Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies.

CONCLUSION

This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

Comparison of Secular Trends in Peptic Ulcer Diseases Mortality in China, Brazil and India during 1990-2019: An Age-Period-Cohort Analysis

BACKGROUND

Peptic ulcer disease (PUD) is a common disease worldwide, especially in developing countries. China, Brazil, and India are among the world's fastest-growing emerging economies. This study aimed to assess long-term trends in PUD mortality and explore the effects of age, period, and cohort in China, Brazil, and India.

METHODS

We collected data from the 2019 Global Burden of Disease Study and used an age-period-cohort (APC) model to estimate the effects of age, period, and cohort. We also obtained net drift, local drift, longitudinal age curve, and period/cohort rate ratios using the APC model.

RESULTS

Between 1990 and 2019, the age-standardized mortality rates (ASMRs) of PUD and PUD attributable to smoking showed a downward trend in all countries and both sexes. The local drift values for both sexes of all ages were below zero, and there were obvious sex differences in net drifts between China and India. India had a more pronounced upward trend in the age effects than other countries. The period and cohort effects had a similar declining trend in all countries and both sexes.

CONCLUSIONS

China, Brazil, and India had an inspiring decrease in the ASMRs of PUD and PUD attributable to smoking and to period and cohort effects during 1990-2019. The decreasing rates of Helicobacter pylori infection and the implementation of tobacco-restricting policies may have contributed to this decrease.

Evidence attack in public health: Diverse actors' experiences with translating controversial or misrepresented evidence in health policy and systems research

Bringing evidence into policy and practice discussions is political; more so when evidence from health studies or programme data are deemed controversial or unexpected, or when results are manipulated and misrepresented. Furthermore, opinion and misinformation in recent years has challenged our notions about how to achieve evidence-informed decision-making (EIDM). Health policy and systems (HPS) researchers and practitioners are battling misrepresentation that only serves to detract from important health issues or, worse, benefit powerful interests. This paper describes cases of politically and socially controversial evidence presented by researchers, practitioners and journalists during the Health Systems Research Symposium 2020. These cases cut across global contexts and range from public debates on vaccination, comprehensive sexual education, and tobacco to more inward debates around performance-based financing and EIDM in refugee policy. The consequences of engaging in controversial research include threats to commercial profit, perceived assaults on moral beliefs, censorship, fear of reprisal, and infodemics. Consequences for public health include research(er) hesitancy, contribution to corruption and leakage, researcher reflexivity, and ethical concerns within the HPS research and EIDM fields. Recommendations for supporting researchers, practitioners and advocates include better training and support structures for responding to controversy, safe spaces for sharing experiences, and modifying incentive structures.

'To be honest, I'm really scared': perceptions and experiences of intimidation in the LMIC-based tobacco control community

BACKGROUND

It is well-evidenced that environmental or human rights advocacy comes with risks for those involved. Much less is known about the risks of tobacco control advocacy despite the emphasis on tobacco industry conduct. This study explores the experiences and perceptions of intimidation among members of the tobacco control community in low- and middle-income countries (LMICs).

METHODS

We interviewed six experts representing each of the World Health Organization (WHO) regions to inform an online survey conducted among the LMIC-based tobacco control community. Thematic analysis was used for analysing qualitative data while quantitative data were analysed descriptively.

RESULTS

Twenty-three participants from five WHO regions completed the survey. Almost three-quarters of survey participants reported that they, or another member of the tobacco control community in their country, had experienced intimidation. The most frequently reported forms of intimidation were discreditation on social or traditional media, legal threats/action and threatening messages. Physical intimidation, theft/burglary, cyberattacks and surveillance were individually rare but reported collectively by over 40% of participants. Results suggested intimidation might be increasing and changing in nature, and undermines tobacco control efforts: it affects organisations' capacity and agenda, their ability to build relationships with those needed to advance policy, as well as the well-being of individuals. Participants used a range of strategies in response to intimidation and reported that they would benefit from better support.

CONCLUSION

This exploratory study suggests that intimidation is a crucial challenge for the tobacco control community. There are several measures the global tobacco control community could take, including establishing an international support mechanism and building capacity to deal with intimidation and draw attention to it.

Health Taxes on Tobacco, Alcohol, Food and Drinks in Low- and Middle-Income Countries: A Scoping Review of Policy Content, Actors, Process and Context

BACKGROUND

Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs.

METHODS

This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O'Malley's scoping review methodology and Walt and Gilson's policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures.

RESULTS

We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors - rather than the presence or absence of particular factors - has the most profound impact on policy implementation.

CONCLUSION

Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.

Seven-year tobacco tax plan in Ukraine: a case study of the actors, tactics and factors motivating policy passage

OBJECTIVE

In December 2017, the Ukrainian Rada passed legislation that would increase tobacco taxes for the next 7 years to meet requirements of the European Union-Ukraine Association Agreement (EU-UAA). We analysed factors motivating passage of Ukraine's 7-year tobacco tax plan as well as tactics used by both opponents and proponents to describe how the plan was passed.

DESIGN

A case study approach was used. Data were gathered from semistructured interviews (n=12) and document review (n=24) and analysed using inductive and deductive coding.

RESULTS

The European Union-Ukraine Association Agreement, a significant budget deficit and a history of tobacco tax success were all contextual factors contributing to policy passage. Proponents of high tobacco taxes capitalised on this opportunity, using media advocacy, generating scientific evidence and collaborating effectively across multiple sectors to support the passage of the plan. Opponents used media advocacy and lobbied to water down several features of the plan, resulting in smaller increases that might not meet EU-UAA requirements.

CONCLUSION

Industry interference via lobbying continues to hamper passage of high tobacco taxes and should be addressed via legislation that aligns with Article 5.3 of the Framework Convention on Tobacco Control. Proponents should look for windows of opportunity caused by external events, create a multisectoral coalition, including tax experts and use media advocacy to support tax increases. Further work should continue to document what contextual factors support tobacco control policy change.

Successful countering of tobacco industry efforts to overturn Thailand's ENDS ban

BACKGROUND

After Thailand enacted laws to ban the import and sale of all types of electronic nicotine delivery systems (ENDS, including e-cigarettes and heated tobacco products (HTPs)) in 2015, pro-ENDS advocacy groups pressured the government to lift the ban, particularly after Philip Morris International (PMI) started promoting its HTP IQOS in 2017.

METHODS

We reviewed information related to ENDS in Thailand between 2014 and 2019 from Thai newspaper articles, meeting minutes and letters submitted to government agencies, websites and social media platforms of pro-ENDS networks and Thai tobacco control organisations.

RESULTS

The tobacco industry and the pro-ENDS groups used five tactics to try to reverse the Thai ban on ENDS: creating front groups, lobbying decision-makers, running public relations campaigns, seeking to discredit tobacco control advocates and funding pro-tobacco harm reduction research. ENDS Cigarette Smoking Thailand (ECST), a pro-ENDS group in Thailand, worked in parallel to Philip Morris Thailand Limited (PMTL) to oppose the ban. The group connected with international coalitions that promote harm reduction through the PMI-funded Foundation for a Smoke-Free World.

CONCLUSION

Although ECST and PMTL continuously worked to revoke the ban since 2017, the government still kept ENDS illegal as of October 2020. This decision resulted from the strong commitment and collaboration among Thai tobacco control organisations and their shared vision to protect the public's health from harmful tobacco products. The similar strategies used by the pro-ENDS movement in Thailand and the tobacco companies could inform health advocates and policy-makers in other low and middle income countries facing pressure to market ENDS.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

Paradox of sustainability in tobacco control in Thailand: A comprehensive assessment of three-decade experiences

BACKGROUND

Over the past 3 decades of tobacco control, Thailand has gained international recognition as a middle-income country with sustained achievement of declining smoking prevalence. However, the number of key Framework Convention on Tobacco Control measures implementation is still far away from the highest-level implementation. As a result, we aim to explore explanatory factors for the paradoxical phenomenon of sustainability in tobacco control in Thailand, to understand what the paradox means, why it happens, and how to take further steps in minimizing the paradox.

METHODS

We used a mixed-method approach comprising qualitative (review of literature and documents plus Program Sustainability Assessment Tool [PSAT] guided key informant interviews) and semi-quantitative methods (PSAT scoring, Theory of Change [TOC], and causal-loop diagram [CLD]) to synthesize all the findings from the qualitative data.

RESULTS

Across all eight domains, sustainability scores at the local level are lower than the national level. The highest total score was in three domains: political support, partnership, and organizational capacity. The lowest total score was for the strategic planning domain. We propose a set of key strategic elements and drivers for future strategic planning.

DISCUSSION

Using CLD, we capture a high-level view of tobacco control with dynamic interactions between contexts, mechanisms, interventions, and outcomes. We believe the deep understanding of tobacco control and the proposed strategy to counteract transnational tobacco companies in Thailand will guide future sustainable actions to reduce the prevalence of smoking, especially in the strategic planning domain that has the lowest PSAT score.

Needs of LMIC-based tobacco control advocates to counter tobacco industry policy interference: insights from semi-structured interviews

INTRODUCTION

Advocacy is vital for advancing tobacco control and there has been considerable investment in this area. While much is known about tobacco industry interference (TII), there is little research on advocates' efforts in countering TII and what they need to succeed. We sought to examine this and focused on low- and middle-income countries (LMICs) where adoption and implementation of the Framework Convention on Tobacco Control (FCTC) tend to remain slower and weaker.

METHOD

We interviewed 22 advocates from eight LMICs with recent progress in a tobacco control policy. We explored participants' experiences in countering TII, including the activities they undertake, challenges they encounter and how their efforts could be enhanced. We used Qualitative Description to analyse transcripts and validated findings through participant feedback.

RESULTS

We identified four main areas of countering activities: (1) generating and compiling data and evidence, (2) accessing policymakers and restricting industry access, (3) working with media and (4) engaging in a national coalition. Each area was linked to challenges, including (1) lack of data, (2) no/weak implementation of FCTC Article 5.3, (3) industry ties with media professionals and (4) advocates' limited capacity. To address these challenges, participants suggested initiatives, including access to country-specific data, building advocates' skills in compiling and using such data in research and monitoring, and in coalition development; others aiming at training journalists to question and investigate TII; and finally, diverse interventions intended to advance a whole-of-government approach to tobacco control. Structural changes to tobacco control funding and coordination were suggested to facilitate the proposed measures.

CONCLUSION

This research highlights that following years of investment in tobacco control in LMICs, there is growing confidence in addressing TII. We identify straightforward initiatives that could strengthen such efforts. This research also underscores that more structural changes to enhance tobacco control capacity building should be considered.

Organizational and Financial Analysis of Polish Tobacco Control Program in 2000-2018

In accordance with the provisions of the WHO Framework Convention on Tobacco Control (FCTC), each country shall promote and strengthen public awareness of tobacco control issues (Article 12). Many parties to the FCTC have adopted national tobacco control programs to organize their tobacco control activities. The aim of our study was to analyze the organization and funding of the Polish Tobacco Control Program in years 2000-2018. Document analysis of The Program and reports from its implementation were performed in accordance to the Agency for Health Technology Assessment in Poland (AHTAPol) recommendations and the WHO FCTC guidelines for Article 12 implementation. Spending was also analyzed. The study showed both inadequate planning of and funding for Polish Tobacco Control Program. The Program was developed without use of best practices detailed in the WHO FCTC guidelines as well as in national guidelines prepared by AHTAPol. The experience of Poland shows that although earmarking tobacco taxes has existed in the law, it has been largely ineffective due to the poor Tobacco Control Program design and insufficient funding resulting from a poor execution of the earmarking law. This may be a warning to other countries to strive to create law, compliance with which can be verified and controlled.

Role of stakeholders in Nigeria's tobacco control journey after the FCTC: lessons for tobacco control advocacy in low-income and middle-income countries

INTRODUCTION

Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. Tobacco control advocates in Nigeria achieved some success in countering tobacco industry interference to implement the FCTC.

METHODS

We triangulated interviews with key informants from local and international organisations who worked in Nigeria with documentation of the legislative process and Nigerian newspaper articles. Data were analysed and interpreted using the Policy Dystopia Model and WHO categories of tobacco industry interference that had been developed mostly based on experience in high-income countries.

RESULTS

As in high-income countries, the tobacco industry continued to oppose tobacco control policies after Nigeria ratified the FCTC, including weakening Nigeria's 2015 National Tobacco Control Act. Both tobacco control advocates and industry used discursive (argument-based) and instrumental (activity-based) strategies. The industry argued self-regulation and the economic importance of tobacco. They exploited legislative procedures, used front groups and third parties to push for pro-industry changes. Advocates, with help from international organisations, mobilised prominent Nigerians and the public. Advocates pre-empted and countered the industry through traditional and social media, monitoring and exposing tobacco industry activities, and by actively engaging lawmakers and citizens during the legislative process.

CONCLUSION

The Policy Dystopia Model and WHO categories of industry interference provide a helpful framework for understanding tobacco control debates in low/middle-income countries (LMICs) as in high-income countries. One difference in LMIC is the important role of international tobacco control advocates in supporting national tobacco control advocates. This partnership is important in pushing for FCTC-compliant legislation and countering industry activities in LMIC.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

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

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

Health systems development in Thailand: a solid platform for successful implementation of universal health coverage

Thailand's health development since the 1970s has been focused on investment in the health delivery infrastructure at the district level and below and on training the health workforce. Deliberate policies increased domestic training capacities for all cadres of health personnel and distributed them to rural and underserved areas. Since 1975, targeted insurance schemes for different population groups have improved financial access to health care until universal health coverage was implemented in 2002. Despite its low gross national income per capita in Thailand, a bold decision was made to use general taxation to finance the Universal Health Coverage Scheme without relying on contributions from members. Empirical evidence shows substantial reduction in levels of out-of-pocket payments, the incidence of catastrophic health spending, and in medical impoverishment. The scheme has also greatly reduced provincial gaps in child mortality. Certain interventions such as antiretroviral therapy and renal replacement therapy have saved the lives of adults. Well designed strategic purchasing contributed to efficiency, cost containment, and equity. Remaining challenges include preparing for an ageing society, primary prevention of non-communicable diseases, law enforcement to prevent road traffic mortality, and effective coverage of diabetes and tuberculosis control.

Defending strong tobacco packaging and labelling regulations in Uruguay: transnational tobacco control network versus Philip Morris International

OBJECTIVE

Describe the process of enacting and defending strong tobacco packaging and labelling regulations in Uruguay amid Philip Morris International's (PMI) legal threats and challenges.

METHODS

Triangulated government legislation, news sources and interviews with policy-makers and health advocates in Uruguay.

RESULTS

In 2008 and 2009, the Uruguayan government enacted at the time the world's largest pictorial health warning labels (80% of front and back of package) and prohibited different packaging or presentations for cigarettes sold under a given brand. PMI threatened to sue Uruguay in international courts if these policies were implemented. The Vazquez administration maintained the regulations, but a week prior to President Vazquez's successor, President Mujica, took office on 1 March 2010 PMI announced its intention to file an investment arbitration dispute against Uruguay in the International Centre for the Settlement of Investment Disputes. Initially, the Mujica administration announced it would weaken the regulations to avoid litigation. In response, local public health groups in Uruguay enlisted former President Vazquez and international health groups and served as brokers to develop a collaboration with the Mujica administration to defend the regulations. This united front between the Uruguayan government and the transnational tobacco control network paid off when Uruguay defeated PMI's investment dispute in July 2016.

CONCLUSION

To replicate Uruguay's success, other countries need to recognise that strong political support, an actively engaged local civil society and financial and technical support are important factors in overcoming tobacco industry's legal threats to defend strong public health regulations.

'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’.

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.

Gaining Insights Into the Waterpipe Tobacco Industry: Participant Observation and a Cross-Sectional Survey of Products at a Trade Exhibition

INTRODUCTION

The rise in waterpipe tobacco smoking has been accompanied by the emergence of a diverse range of products, such as "herbal" waterpipe tobacco substitutes and electronic waterpipes. The aims of this study were to assess the extent to which emerging waterpipe products are being developed by waterpipe tobacco companies themselves, to understand the key characteristics of the main market players, and to examine the connections between producers of different product categories.

METHODS

In 2014, one researcher attended an international waterpipe trade exhibition in Germany, conducting a survey of products at exhibition stands, and gathering qualitative data on exhibitors and products using participant observation. Cross-tabulations and chi-square tests identified the association between waterpipe tobacco, waterpipe tobacco substitutes, and electronic waterpipe products. We thematically analyzed field notes into information about exhibitors and products.

RESULTS

Of 97 exhibitors, 55 displayed waterpipe-related products. Of these, nearly half (45%) displayed electronic waterpipe products, 38% displayed waterpipe tobacco and 23% displayed waterpipe tobacco substitutes. There was an inverse association between the display of waterpipe tobacco and electronic waterpipe products, and a positive association between the display of waterpipe tobacco and waterpipe tobacco substitutes. We found that Japan Tobacco Inc, Philip Morris, and British American Tobacco were partnered or affiliated with exhibitors displaying waterpipe-related products.

CONCLUSIONS

Electronic waterpipe products were the main feature of this exhibition. Waterpipe tobacco substitutes are likely to be produced by the waterpipe tobacco industry whereas electronic waterpipes are not. There is a developing interest in waterpipe-related products by transnational tobacco corporations. Further industry surveillance is warranted.

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.

Term limits and the tobacco industry

In the 1990s several American states passed term limits on legislators with the stated intention of reducing the influence of wealthy industries on career legislators. Although term limits in the United States do not have a direct relationship to public health, the tobacco industry anticipated that term limits could have indirect effects by either limiting or expanding industry influence. We detail the strategy of the tobacco industry in the wake of term limits using internal tobacco company documents and a database of campaign contributions made to legislators in term limited states between 1988 and 2002. Despite some expectations that term limits would limit tobacco industry access to state legislators, term limits appear to have had the opposite effect.

Exploring the implementation of the framework convention on tobacco control in four small island developing states of the Pacific: a qualitative study

OBJECTIVES

To determine what variables influence the implementation of the Framework Convention on Tobacco Control (FCTC) in small island developing states of the Pacific and how they affect its success or failure. To explore how barriers can be overcome and opportunities utilised to ensure an effective FCTC implementation in the Pacific Islands.

DESIGN

A mixed methods, multiple case study consisting of primarily qualitative data in the form of semistructured interviews, document analysis and opportunistic observation.

SETTING

Field visits were undertaken to collect data in the Cook Islands, Vanuatu, Palau and Nauru. The key informants were interviewed in the major cities or islands of each respective country: Rarotonga, Port Vila, Koror and Nauru.

PARTICIPANTS

Purposive sampling was used to select 39 informants, whose roles were associated with FCTC implementation. Most of the participants worked in health-oriented positions in the government and non-government organisations.

RESULTS

Each country made a significant progress towards FCTC implementation. Overall, strong policy content, public support and limited pro-tobacco coalition activity were conducive to FCTC implementation, but the challenges were evident in the form of limited capacity, limited antitobacco coalition activity and limited political commitment outside the ministries of health in each country.

CONCLUSIONS

Further efforts are needed for full FCTC implementation, through building capacity and using resources effectively, growing commitment to FCTC beyond the health sector, fostering growth in antitobacco coalition activity, exploiting the limited pro-tobacco activity that may be present and garnering public support for tobacco control. These lessons may be particularly important for other small island developing states in the Pacific and developing countries elsewhere.

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

Tobacco use is the biggest single preventable cause of non-communicable diseases (NCDs) in the Western Pacific region. Currently, 14 Pacific Island countries have ratified the WHO Framework Convention on Tobacco Control (FCTC) and, in having done so, are committed to implementing tobacco control measures aligned with the FCTC. Progressing strong and effective tobacco control legislation is essential to achieving long term gains in public health in small island countries. However, survey evidence suggests that pervasive tobacco industry interference serves to undermine tobacco control and public policy in several Pacific countries. An initiative was developed to provide dedicated, in-country technical support for developing legislation and policy to support implementation of Article 5.3 of the FCTC in the Solomon Islands and Papua New Guinea. This paper examines the factors that have assisted the two Pacific countries to make progress in implementing Article 5.3 and what this might mean for supporting progress in other Pacific settings. A document analysis was undertaken to identify the process and outcome of the intervention. Two significant outputs from the project including having identified and documented specific examples of TII and the development of draft legislation for Article 5.3 and other key resources for public servants both within and outside the health sector. Key determinants of progress included a motivated and engaged Ministry of Health, active civil society group or champion and access to media to prepare tobacco industry related material to stimulate public and policy sector debate.