British Columbia capital regional district 100% smokefree bylaw: a successful public health campaign despite industry opposition

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.

Tobacco control law implementation in a middle-income country: Transnational tobacco control network overcoming tobacco industry opposition in Colombia

The objective of this paper is to examine the implementation of Colombia's tobacco control law. Methods involved are triangulated government legislation, news sources, and interviews with policy-makers and health advocates in Colombia. Colombia, a middle-income country, passed a tobacco control law in 2009 that included a prohibition on tobacco advertising, promotion, and sponsorship; and required pictorial health warning labels, ingredients disclosure, and a prohibition on individual cigarette sales. Tobacco companies challenged the implementation through litigation, tested government enforcement of advertising provisions and regulations on ingredients disclosure, and lobbied local governments to deprioritise policy responses to single cigarette sales. A transnational network including international health groups and funders helped strengthen domestic capacity to implement the law by; promoting public awareness of Ley [Law] 1335; training local health department staff on enforcement; facilitating health agencies' sharing of educational strategies; and providing legal defence assistance. This network included vigilant efforts by local health groups, which continuously monitored and alerted the media to noncompliance, engaged government officials and policy-makers on implementation, and raised public awareness. Support from international health NGOs and funders and continuous engagement by local health groups enhanced implementation capacities to counter continued tobacco industry interference and ensure effective tobacco control implementation.

Smokefree implementation in Colombia: Monitoring, outside funding, and business support

Objective:

To analyze successful national smokefree policy implementation in Colombia, a middle income country.

Materials and methods:

Key informants at the national and local levels were interviewed and news sources and government ministry resolutions were reviewed.

Results:

Colombia's Ministry of Health coordinated local implementation practices, which were strongest in larger cities with supportive leadership. Nongovernmental organizations provided technical assistance and highlighted noncompliance. Organizations outside Colombia funded some of these efforts. The bar owners' association provided concerted education campaigns. Tobacco interests did not openly challenge implementation.

Conclusions:

Health organization monitoring, external funding, and hospitality industry support contributed to effective implementation, and could be cultivated in other low and middle income countries.

The carrot and the stick? Strategies to improve compliance with college campus tobacco policies

OBJECTIVE

Tobacco-free policies are being rapidly adopted nationwide, yet compliance with these policies remains a challenge. This study explored college campus key informants' experiences with tobacco policies, and their perceived benefits, drawbacks, and outcomes.

PARTICIPANTS

The sample for this study was 68 key informants representing 16 different California universities with varying tobacco policies (no smoking indoors and within 20 feet of entrances, designated smoking areas, 100% smoke-free, and 100% tobacco-free).

METHODS

Qualitative, descriptive study. Semistructured interviews were transcribed verbatim and analyzed using content analysis.

RESULTS

Strategies to improve compliance ranged from a social approach to a heavy focus on punitive enforcement. Key informants from campuses using a social approach alone reported barriers to improving compliance, including a perceived lack of efficacy of the approach. However, these campuses found it challenging to incorporate enforcement through campus police or security.

CONCLUSIONS

College campus decision makers should explore using a combined approach (social approach as well as formal enforcement), with enforcement primarily the responsibility of nonpolice university channels (eg, Student Affairs, employee supervisors).

Differences in lung cancer mortality trends from 1986-2012 by radon risk areas in British Columbia, Canada

Residential exposure to radon gas is associated with increased risk of lung cancer, especially in smokers. Most evidence about the health effects of radon has been derived from meta-analyses on global epidemiologic studies, but administrative data can help public health authorities to explore the local impacts. Eighty health units in British Columbia (BC), Canada, were classified as having low, moderate, or high radon risk using more than 3,800 residential measurements. Vital statistics records were used to identify deaths due to lung cancer and to all natural causes. The annual ratio of lung cancer mortality to all natural mortality was plotted for the 1986-2012 study period for each radon classification. Visualizations were stratified by gender and by smoking prevalence. The overall ratio increased throughout the study period in high radon areas and remained stable in low and moderate radon areas. The increase was most pronounced for females, especially when plots were stratified by smoking prevalence. These limited but interesting findings confirm that radon is one risk factor for lung cancer mortality in BC and that its effects differ across gender and smoking strata. The results would be strengthened by replication, and more rigorous methods are required to assess other contributing factors.

Failure of policy regarding smoke-free bars in the Netherlands

BACKGROUND

Tobacco companies consistently work to prevent and undermine smoke-free laws. The tobacco industry and its allies have funded hospitality associations and other third parties to oppose smoke-free laws, argue that smoke-free laws will economically damage hospitality venues, promote ventilation and voluntary smoker 'accommodation' as an alternative to smoke-free laws, and to challenge smoke-free laws in court. In 2008, the Netherlands extended its smoke-free law to hospitality venues.

METHODS

We triangulated news articles, government documents, scientific papers, statistical reports and interviews to construct this case study.

RESULTS

Despite widespread public support for smoke-free hospitality venues, opponents successfully represented these laws as unpopular and damaging to small bars. These challenges and related smokers' rights activities resulted in non-compliance among all bars and reinstating an exemption for small, owner-run venues. This policy reversal was the result of a weak implementing media campaign (which failed to present the law as protecting nonsmokers), smoking room exemptions and reactive (vs. proactive) measures by the Ministry of Health and civil society.

CONCLUSION

The policy failure in the Netherlands is the result of poor implementation efforts and the failure to anticipate and deal with opposition to the law. When implementing smoke-free laws it is important to anticipate opposition, used the media to target non-smokers to reinforce public support, and actively enforce the law.

Addressing the common pathway underlying hypertension and diabetes in people who are obese by maximizing health: the ultimate knowledge translation gap

In accordance with the WHO definition of health, this article examines the alarming discord between the epidemiology of hypertension, type 2 diabetes mellitus (T2DM), and obesity and the low profile of noninvasive (nondrug) compared with invasive (drug) interventions with respect to their prevention, reversal and management. Herein lies the ultimate knowledge translation gap and challenge in 21st century health care. Although lifestyle modification has long appeared in guidelines for medically managing these conditions, this evidence-based strategy is seldom implemented as rigorously as drug prescription. Biomedicine focuses largely on reducing signs and symptoms; the effects of the problem rather than the problem. This article highlights the evidence-based rationale supporting prioritizing the underlying causes and contributing factors for hypertension and T2DM, and, in turn, obesity. We argue that a primary focus on maximizing health could eliminate all three conditions, at best, or, at worst, minimize their severity, complications, and medication needs. To enable such knowledge translation and maximizing health outcome, the health care community needs to practice as an integrated team, and address barriers to effecting maximal health in all patients. Addressing the ultimate knowledge translation gap, by aligning the health care paradigm to 21st century needs, would constitute a major advance.

Strong advocacy led to successful implementation of smokefree Mexico City

OBJECTIVE

To describe the approval process and implementation of the 100% smokefree law in Mexico City and a competing federal law between 2007 and 2010.

METHODS

Reviewed smokefree legislation, published newspaper articles and interviewed key informants.

RESULTS

Strong efforts by tobacco control advocacy groups and key policymakers in Mexico City in 2008 prompted the approval of a 100% smokefree law following the WHO FCTC. As elsewhere, the tobacco industry utilised the hospitality sector to block smokefree legislation, challenged the City law before the Supreme Court and promoted the passage of a federal law that required designated smoking areas. These tactics disrupted implementation of the City law by causing confusion over which law applied in Mexico City. Despite interference, the City law increased public support for 100% smokefree policies and decreased the social acceptability of smoking. In September 2009, the Supreme Court ruled in favour of the City law, giving it the authority to go beyond the federal law to protect the fundamental right of health for all citizens.

CONCLUSIONS

Early education and enforcement efforts by tobacco control advocates promoted the City law in 2008 but advocates should still anticipate continuing opposition from the tobacco industry, which will require continued pressure on the government. Advocates should utilise the Supreme Court's ruling to promote 100% smokefree policies outside Mexico City. Strong advocacy for the City law could be used as a model of success throughout Mexico and other Latin American countries.

Local smoke-free policy development in Santa Fe, Argentina

OBJECTIVE

To describe the process of approval and implementation of a comprehensive smoke-free law in the province of Santa Fe, Argentina, between 2005 and 2009.

METHODS

Review of the Santa Fe smoke-free legislation, articles published in local newspapers and documentation on two lawsuits filed against the law, and interviews with key individuals in Santa Fe.

RESULTS

Efforts to implement smoke-free policies in Santa Fe began during the 1990s without success, and resumed in 2005 when the provincial Legislature approved the first 100% smoke-free subnational law in Argentina. There was no strong opposition during the discussions within the legislature. As in other parts of the world, pro-tobacco industry interests attempted to block the implementation of the law using well known strategies. These efforts included a controversy media campaign set up, the creation of a hospitality industry association and a virtual smokers' rights group, the introduction of a counterproposal seeking modification of the law, the challenge of the law in the Supreme Court, and the proposal of a weak national bill that would 'conflict' with the subnational law. Tobacco control advocates sought media attention as a strategy to protect the law.

CONCLUSIONS

Santa Fe is the first subnational jurisdiction in Latin America to have enacted a comprehensive smoke-free policy following the recommendations of the World Health Organization (WHO) Framework Convention on Tobacco Control. After 3 years of implementation, pro-tobacco industry forces failed to undermine the law. Other subnational jurisdictions in Argentina, as well as in Mexico and Brazil are following the Santa Fe example.

Moving toward people's needs for smoke-free restaurants: before and after a national promotion program in Taiwan, 2003-2005

INTRODUCTION

In Taiwan, the Smoke-Free Restaurant Program (SFRP) was implemented from 2003 to 2005 as an initial phase before the introduction of restrictive legislation promoting smoke-free restaurants (SFRs). No studies have evaluated trends in public opinion before and after a national health promotion campaign for the introduction of SFRs on a voluntary basis. The present study investigated whether public opinion with respect to eliminating environmental tobacco smoke (ETS) in restaurants changed after implementation of the SFRP.

METHODS

Data were obtained from four large-scale, nationally representative surveys conducted in 2003-2005 before and after implementation of the SFRP. Weighted analyses were performed to obtain nationally representative results.

RESULTS

After a series of SFRP campaigns, reported exposure to ETS in restaurants by survey participants decreased by approximately 14%. Approximately 20% more people had heard of SFRs, and approximately 25% more had chosen to dine in a smoke-free restaurant. We found consistently high community support for SFRs (ca. 95%), and approximately 80% supported smoke-free restaurant legislation, although both rates dropped slightly in 2005. People aged 60 years or more, nonsmokers, and those who had greater knowledge of ETS hazards were more likely to support smoke-free restaurant legislation.

DISCUSSION

The SFRP was effective at promoting SFRs on a voluntary basis. Strong community endorsement has major implications for legislators who are considering the nature and extent of further smoke-free restaurant legislation in Taiwan and other countries.

The Community Readiness Model: evaluating local smoke-free policy development

The purpose of this article is to review the literature on community readiness and assess the utility of the community readiness model (CRM) for understanding and affecting smoke-free policy development and implementation. The CRM evaluates a community's capacity for successfully developing and implementing prevention or treatment interventions. The purposes of evaluating a community's readiness are to: (a) identify the stage of readiness for policy change, and (b) determine stage-specific strategies to advance a community toward policy change.

"Accommodating" smoke-free policies: tobacco industry's Courtesy of Choice programme in Latin America

OBJECTIVE

To understand the implementation and effects of the Courtesy of Choice programme designed to "accommodate" smokers as an alternative to smoke-free policies developed by Philip Morris International (PMI) and supported by RJ Reynolds (RJR) and British American Tobacco (BAT) since the mid-1990s in Latin America.

METHODS

Analysis of internal tobacco industry documents, BAT "social reports", news reports and tobacco control legislation.

RESULTS

Since the mid-1990s, PMI, BAT and RJR promoted Accommodation Programs to maintain the social acceptability of smoking. As in other parts of the world, multinational tobacco companies partnered with third party allies from the hospitality industry in Latin America. The campaign was extended from the hospitality industry (bars, restaurants and hotels) to other venues such as workplaces and airport lounges. A local public relations agency, as well as a network of engineers and other experts in ventilation systems, was hired to promote the tobacco industry's programme. The most important outcome of these campaigns in several countries was the prevention of meaningful smoke-free policies, both in public places and in workplaces.

CONCLUSIONS

Courtesy of Choice remains an effective public relations campaign to undermine smoke-free policies in Latin America. The tobacco companies' accommodation campaign undermines the implementation of measures to protect people from second-hand smoke called for by the World Health Organization Framework Convention on Tobacco Control, perpetuating the exposure to tobacco smoke in indoor enclosed environments.

A pilot qualitative study of New Zealand policymakers' knowledge of, and attitudes to, the tobacco industry

BACKGROUND

The actions of policymakers are critical to advancing tobacco control. To evaluate the feasibility of using anonymous in-depth interviews to ascertain policymakers' knowledge about, and attitudes to, the tobacco industry, we undertook a pilot study involving New Zealand policymakers.

METHODS

Five politicians (from different political parties) and five senior officials, who were involved in tobacco control policy, were recruited for semi-structured, anonymous, face-to-face interviews.

RESULTS

Recruitment of appropriate senior policymakers was found to be possible. Interviewees were willing to answer questions fully and frankly about their knowledge and views of the tobacco industry.The preliminary data from this pilot suggest that some New Zealand politicians appeared to see contact with the industry as similar to contact with other groups, whereas the officials indicated at least a different style of relationship. Only one politician knew if their party accepted funding from tobacco companies. All but one of the interviewees thought that promotion of tobacco to under-16 s still occurs, albeit indirectly. The interviewees' knowledge of the investment in tobacco industries by New Zealand government agencies was low or absent.While most of those interviewed showed scepticism about tobacco company public relations efforts, this was absent in some cases. There was a wide understanding that the tobacco industry will use many tactics in the pursuit of profit, and to counteract government efforts to reduce the harm from smoking.

CONCLUSION

In-depth anonymous interviews appear to be feasible and can be productive for exploring sensitive tobacco-related policy issues with policymakers. The preliminary data from this group of New Zealand policymakers suggest important knowledge gaps, but also general distrust of this industry. From a tobacco control perspective, the results may suggest a greater focus by advocates on the funding of political parties by the tobacco industry, and on government agency investment in the tobacco industry.

Free nicotine replacement therapy programs vs implementing smoke-free workplaces: a cost-effectiveness comparison

We compared the cost-effectiveness of a free nicotine replacement therapy (NRT) program with a statewide smoke-free workplace policy in Minnesota. We conducted 1-year simulations of costs and benefits. The number of individuals who quit smoking and the quality-adjusted life years (QALYs) were the measures of benefits. After 1 year, a NRT program generated 18,500 quitters at a cost of 7020 dollars per quitter (4440 dollars per QALY), and a smoke-free workplace policy generated 10,400 quitters at a cost of 799 dollars per quitter (506 dollars per QALY). Smoke-free work-place policies are about 9 times more cost-effective per new nonsmoker than free NRT programs are. Smoke-free workplace policies should be a public health funding priority, even when the primary goal is to promote individual smoking cessation.

Hedging their bets: tobacco and gambling industries work against smoke-free policies

OBJECTIVE

To describe and understand the relationship between the tobacco and gambling industries in connection to their collaborative efforts to prevent smoke-free casinos and gambling facilities and fight smoke-free policies generally.

METHODS

Analysis of tobacco industry documents available online (accessed between February and December 2003).

RESULTS

The tobacco industry has worked to convince the gambling industry to fight against smoke-free environments. Representatives of the gambling industry with ties to the tobacco industry oppose smoke-free workplaces by claiming that smoke-free environments hurt gambling revenue and by promoting ventilation as a solution to secondhand smoke. With help from the tobacco industry, the gambling industry has become a force at the American Society of Heating Refrigeration and Air Conditioning Engineers opposing smoke-free ventilation standards for the hospitality industry.

CONCLUSION

Tobacco industry strategies to mobilise the gambling industry to oppose smoke-free environments are consistent with past strategies to co-opt the hospitality industry and with strategies to influence policy from behind the scenes. Tobacco control advocates need to be aware of the connections between the tobacco and gambling industries in relation to smoke-free environments and work to expose them to the public and to policy makers.