The importance of continued engagement during the implementation phase of tobacco control policies in a middle-income country: the case of Costa Rica

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries

OBJECTIVE

To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico.

DESIGN

Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022).

RESULTS

In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing.

CONCLUSION

Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

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.

Corporate Political Activity: Taxonomies and Model of Corporate Influence on Public Policy

BACKGROUND

Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective counter-measures by formulating a model and evidence-informed taxonomies of UCI political activity.

METHODS

We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature.

RESULTS

We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies - one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry's advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context.

CONCLUSION

Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

Progress in adopting bans on tobacco advertising, promotion, and sponsorship in the Americas: lessons from Uruguay and Argentina

Objective.

To assess progress in and barriers to implementing bans on tobacco advertising, promotion and sponsorship (TAPS) in Uruguay, which has a complete ban, and Argentina, with a partial ban.

Methods.

Legislation on TAPS bans in Uruguay and Argentina was reviewed and relevant published literature, news stories, civil society reports and tobacco industry reports retrieved to analyze progress in implementing TAPS bans.

Results.

In Uruguay, the complete TAPS ban, which includes standardized tobacco packaging, maintains high compliance and severely limits exposure of TAPS, despite a few problems with corporate social responsibility, social media, and transnational advertising. In Argentina, the partial TAPS ban has more problems with compliance and exposure to TAPS. The most important barriers to implementing TAPS bans in both countries are the tobacco companies. In Uruguay, tobacco companies do not comply in a few areas but the complete ban greatly minimizes this. In Argentina, however, tobacco companies can more easily exploit gaps in the partial TAPS ban, such as advertising at the points of sale, promoting contests, and using influencers on social media.

Conclusions.

The partial TAPS ban in Argentina illustrates the problems with enforcement and the tobacco industry’s ability to exploit loopholes and continue to market their products, especially to young people. A complete TAPS ban, including standardized tobacco packaging, as in Uruguay, is easier to implement and enforce and is effective in reducing exposure to tobacco advertising. Nevertheless, governments should prioritize implementing TAPS bans on social media, which remains a difficult sphere to monitor and allows tobacco companies to continue recruiting and targeting young people.

Tobacco industry thwarts ad ban legislation in India in the 1990s: Lessons for meeting FCTC obligations under Articles 13 and 5.3

Bans on tobacco advertising are important for reducing tobacco-caused disease. Previously secret internal tobacco industry documents and organizational and newspaper websites related to tobacco control efforts in India during 1990s were analyzed. The Ministry of Health and Family Welfare, World Health Organization, Indian Council of Medical Research, and civil society played important roles in pushing for tobacco control legislation beginning in the 1980s. Guided by transnational tobacco companies, especially British American Tobacco, Philip Morris International, and RJ Reynolds, Indian cigarette companies formed the Tobacco Institute of India (TII). Following the industry's global strategy, TII proposed voluntary advertising codes, used diplomatic channels and high level political and judicial lobbying, and allied with other industry, sports and trade groups to delay legislation for ten years. TII argued for the social and economic importance of tobacco and that laws were unnecessary, unconstitutional, and would hurt the economy. These early global strategies were continuing in 2022 to delay and evade legislative efforts to ban tobacco advertising. Understanding these strategies can inform public health efforts to counter industry efforts to thwart the WHO Framework Convention on Tobacco Control in 2022 not only in India, where the Ministry of Health and Family Welfare has proposed strengthening India's tobacco control law, but globally.

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.

Global Implementation of Tobacco Demand Reduction Measures Specified in Framework Convention on Tobacco Control

INTRODUCTION

The world's first global health treaty, WHO Framework Convention on Tobacco Control (FCTC) aims to reduce tobacco product demand by focusing on tobacco taxes, smoking bans, health warning labels, and tobacco advertising bans. Previous studies almost unanimously suggest that FCTC has prompted countries to implement more effective tobacco demand reduction policies.

AIMS AND METHODS

By taking into account the pre-FCTC status, country income level, and state capacity we studied if ratifying FCTC was associated with tobacco demand reduction measures in 2018/2019. We used logistic regression to assess the association of FCTC ratification with adoption demand reduction measures, accounting for years since ratification, baseline status, and other covariates.

RESULTS

Except for taxes, state of tobacco policy implementation before FCTC ratification did not predict adoption of FCTC policies. Time since FCTC ratification was associated with implementing smoking bans and pictorial HWLs. In contrast, while the tax rate prior to FCTC ratification was positively associated with increased taxes after FCTC ratification, time since FCTC ratification was marginally negatively associated with increases in tobacco taxes.

CONCLUSIONS

While the FCTC was followed by implementation of compliant demand reduction policies, there are still many parties that have not implemented the FCTC, particularly increasing taxes and ending tobacco advertising and promotions.

IMPLICATIONS

We assessed changes in tobacco demand reductions measures over 22 years in 193 countries. By using internal tobacco industry documents, we were able establish a baseline before the FCTC negotiations. Unlike previous studies, we included four tobacco demand reductions measures: tobacco taxes, smoking bans, health warning labels, and tobacco advertising ban. The limitation of the study is that we do not have data to describe if demand reduction measures are actually enforced or what their effect on tobacco consumption is.

Tobacco Control In Bolivia: Transnational Civil Society Efforts In Securing A Comprehensive Law

OBJECTIVE

To document the adoption of a comprehensive tobacco control law in Bolivia, a low-income country in South America.

METHODS

Analysis of the Bolivian case study by reviewing news sources, tobacco control legislation, industry websites, and advocacy reports. Application of the Policy Dystopia Model to analyze tobacco industry and health advocacy arguments and action-based strategies.

RESULTS

For decades tobacco control progress in Bolivia remained relatively stagnant due to industry interference. In the 2000s and 2010s Bolivia ratified the WHO Framework Convention on Tobacco Control (FCTC) and implemented a couple of laws that began restricting smoking in public places and tobacco advertising. In 2015, tobacco control civil society emerged with the creation of FIC Bolivia, which began coordinating efforts to counter industry interference. Between 2016 and 2020 FIC Bolivia with financial and technical support from international health groups proactively coordinated inter-ministerial meetings, identified and met with key policymakers, and held public educational socialization events to introduce and support a FCTC-based tobacco control bill. Tobacco companies argued to policymakers and the media the bill would result in lost sales/jobs, increase illicit trade and help smugglers profit but only secured minimal changes. In February 2020, Bolivia passed Law 1280, which established 100% smoke-free environments, banned tobacco advertising (except at the point-of-sale), required 60% pictorial health warnings, among others.

CONCLUSION

International financial and technical support combined with proactive advocacy strategies, including identifying and engaging key policymakers, coordinating inter-ministerial meetings, and educating the public can help pass strong tobacco control laws, especially in low-income countries.

IMPLICATIONS

Low and middle-income countries struggle to adopt comprehensive tobacco control legislation due to weak state capacity, limited resources and aggressive tobacco industry interference. This is one of a handful of studies to examine the adoption of a comprehensive tobacco control law in a low-income country, Bolivia. Proactive health advocacy strategies, including identifying and engaging key political allies, helping coordinate inter-ministerial meetings, and aggressively educating and engaging the public can help pass strong tobacco control laws, especially in low-income countries.

Evidence on article 5.3 of FCTC (tobacco industry interference in tobacco control activities) in India- a qualitative scoping study

BACKGROUND

The Tobacco Industry (henceforth TI) yearns to portray itself as being "socially responsible" and fights for the decision-making positions; that are it used to deter, delay or dilute tobacco control measures. There is little documented evidence of Tobacco Industry Interference (henceforth TII) from India, the scope of their interference and challenges faced by the experts for effective tobacco control. This research study seeks to cover this significant gap in the literature on the TI of India.

METHODS

A cross-sectional qualitative research design, based upon in-depth interviews (N = 26), was used to explore the key stakeholders' opinions regarding TII in India. The interviews used a set of questions to collect information about the participant's roles and responsibilities in tobacco control, the nature of TII faced by the participants, means of influence by TI, barriers and challenges to tobacco control efforts.

RESULTS

Most of the respondents were engaged in tobacco control, training, advocacy and awareness generation activities for 5-10 years or more. The respondents defined the TI and its scope as per their experience with the help of the power ranking methodology. Most of them perceived TI as 'manufacturers' while others consider them as 'advertisers', 'public relation companies', 'wholesalers', 'vendors', and 'Government firms with TI stocks. The research team identified six significant domains: influencing the policy and administrative decisions, Interference in the implementation of tobacco control laws and activities, false propaganda and hiding the truth, manipulating front action groups (FAG), rampant tobacco advertising and promotion activities and others under which TII activities were classified. Most respondents believed that TI players were interfering in the policy decisions, implementing the tobacco control laws and activities and manipulating the FAG. A detailed taxonomic classification of the TII strategies that emerged from our analysis was linked to article 5.3 of FCTC.

CONCLUSIONS

The study documented a significant level of TII in different domains, with stakeholders acting at various hierarchical levels. Thus providing insight into the tactics of the TI in order to enable stakeholders to anticipate and pre-empt the kinds of alliances the TI may attempt to build; stimulating academicians and researchers to undertake in-depth analysis into various strategies and therefore underscoring the need to ensuring transparency in official interaction with the TI and its representatives.

Food and beverage industry interference in science and policy: efforts to block soda tax implementation in Mexico and prevent international diffusion

Mexico is the largest soft drink market in the world, with high rates of obesity and type 2 diabetes. Due to strains on the nation’s productivity and healthcare spending, Mexican lawmakers implemented one of the world’s first public health taxes on sugar-sweetened beverages (SSBs) in 2014. Because Mexico’s tax was designed to reduce SSB consumption, it faced strong opposition from transnational food and beverage corporations. We analysed previously secret internal industry documents from major corporations in the University of California San Francisco’s Food Industry Documents Archive that shed light on the industry response to the Mexican soda tax. We also reviewed all available studies of the Mexican soda tax’s effectiveness, contrasting the results of industry-funded and non-industry-funded studies. We found that food and beverage industry trade organisations and front groups paid scientists to produce research suggesting that the tax failed to achieve health benefits while harming the economy. These results were disseminated before non-industry-funded studies could be finalized in peer review. Mexico still provided a real-world context for the first independent peer-reviewed studies documenting the effectiveness of soda taxation—studies that were ultimately promoted by the global health community. We conclude that the case of the Mexican soda tax shows that industry resistance can persist well after new policies have become law as vested interests seek to roll back legislation, and to stall or prevent policy diffusion. It also underscores the decisive role that conflict-of-interest-free, peer-reviewed research can play in implementing health policy innovations.

'You cannot touch taxes easily': making the case for tobacco taxation in India

India represents over 1.3 billion people with >100 million adult smokers. The catastrophic health costs of smoking are staggering; and estimates show that even modest increases in taxes on cigarettes and bidis would both raise substantial revenues for the government and save ∼69 million years of healthy life over the next four decades. Karnataka represents a good example of tobacco control efforts and their impact. This case study examines the factors that have contributed to tobacco control policy in Karnataka based on 23 semi-structured interviews with key informants engaged in tobacco policymaking and decision-making, tobacco control/taxation research and advocacy. Their narratives indicate that: (i) Domestic taxation policy is complicated by the complex tax structure and centralized control over taxation with the introduction of Goods and Services Tax; (ii) Implementation of legal frameworks is a challenge, due to conflicts with powerful industry and farmer lobbies. A vigorous civil society backed by the Courts is necessary to garner political support; (iii) Action on taxation is hampered by weak leadership and mixed messaging; and (iv) There is a need for innovative policy solutions to promote both demand- and supply-side measures for tobacco control. Tobacco control advocates need to recognize the political economy of tobacco control and generate strong, reliable and scientifically sound evidence to support their arguments. Working for incremental 'wins' in terms of more stringent application of existing legal frameworks can make a substantial difference even in contexts where enhancing tobacco taxes is a challenge. Promoting multisectoral action is critical, at both policy and the ground levels, by expanding ownership and responsibility for tobacco control to sectors beyond health. Finally, the health sector needs to recommit to its role as a champion for tobacco control. Failure to do so would amount to a failure on multiple fronts-public health, economic, fiscal and ethical.

Exceeding WHO Framework Convention on Tobacco Control (FCTC) Obligations: Nepal Overcoming Tobacco Industry Interference to Enact a Comprehensive Tobacco Control Policy

BACKGROUND

The tobacco industry works to block, delay, and weaken national tobacco control legislation to implement the WHO Framework Convention on Tobacco Control (FCTC). This article reviews how Nepal overcame industry opposition and to a comprehensive tobacco control law implementing the FCTC.

METHODS

We triangulated newspaper articles and policy documents with key informant interviews.

RESULTS

With the support of international health groups, local tobacco control advocates worked with policymakers in Nepal to pass a comprehensive tobacco control law that exceeded FCTC obligations. The tobacco industry exploited a time of political transition to block consideration by Parliament, arranged and sponsored foreign tours for legislators, made death threats to tobacco control advocates and their families, and argued for the economic importance of tobacco farms. Despite strong interference from Health, and Law and Justice ministers, a 2009 Supreme Court ruling helped tobacco control advocates secure a comprehensive tobacco control law in 2011 that included rotating pictorial health warning labels covering 75% of both sides of cigarette packages, 100% smoke free public places and workplaces, private homes and vehicles, and a tobacco advertising, promotion, and sponsorship ban.

CONCLUSIONS

Advocates in developing countries should utilize Nepal's experience to reject tobacco industry offers of compromise and continue educating politicians and legislators to generate political support to pass a comprehensive tobacco control law. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak (the abstract in Nepali is available as a Supplementary Material).

IMPLICATIONS

The tobacco industry exploited a time of political transition in Nepal in its effort to block comprehensive tobacco control policy in Parliament by sponsoring foreign tours of legislatures, making death threats to tobacco control advocates and their families, and arguing for the economic importance of tobacco farms. Tobacco control advocates used litigation to raise awareness and educate legislators and promote strong legislation with the involvement of international health groups. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak.

Defending Comprehensive Tobacco Control Policy Implementation in Nepal From Tobacco Industry Interference (2011-2018)

INTRODUCTION

Nepal passed a comprehensive tobacco control law in 2011. Tobacco control advocates successfully countered tobacco industry (TI) interference to force implementation of law.

AIMS AND METHODS

Policy documents, news stories, and key informant interviews were triangulated and interpreted using the Policy Dystopia Model (PDM).

RESULTS

The TI tried to block and weaken the law after Parliament passed it. Tobacco control advocates used litigation to force implementation of the law while the TI used litigation in an effort to block implementation. The TI argued that tobacco was socially and economically important, and used front groups to weaken the law. Tobacco control advocates mobilized the media, launched public awareness campaigns, educated the legislature, utilized lawsuits, and monitored TI activities to successfully counter TI opposition.

CONCLUSIONS

Both tobacco control advocates and the industry used the discursive and instrumental strategies described in the PDM. The model was helpful for understanding TI activities in Nepal and could be applied to other low- and middle-income countries. Civil society, with the help of international health groups, should continue to track TI interference and learn the lessons from other countries to proactively to counter it.

IMPLICATIONS

The PDM provides an effective framework to understand battles over implementation of a strong tobacco control law in Nepal, a low- and middle-income country. The TI applied discursive and instrumental strategies in Nepal in its efforts to weaken and delay the implementation of the law at every stage of implementation. It is important to continuously monitor TI activities and learn lessons from other countries, as the industry often employ the same strategies globally. Tobacco control advocates utilized domestic litigation, media advocacy, and engaged with legislators, politicians, and other stakeholders to implement a strong tobacco control law. Other low- and middle-income countries can adapt these lessons from Nepal to achieve effective implementation of their laws.

The Application of Philip Morris' Litigation Prevention Program in South Korea

This article is aimed to identify the strategies of Philip Morris (PM, before its spin-off in 2003) and its affiliates in the intervention and prevention of tobacco litigation in South Korea. We analyzed 193 documents obtained from the Truth Tobacco Industry Documents. We found that PM organized and operated the "Litigation Prevention Program (LPP)" to create legal environments making tobacco litigation difficult to initiate and legal networks with local lawyers, media, and even competitors to effectively respond to such litigations. PM developed the LPP based on its legal strategies in the United States against tobacco litigation and disseminated them all around the world including South Korea. In 1999, the first joint action against Korea Tobacco and Ginseng Corporate (KTGC, today known as KT&G), a state-owned tobacco company, began. KTGC asked PM to support their litigation, and PM provided its legal strategies, such as sources to counter the plaintiffs' arguments, through the LPP to KTGC. In front of legal threats, tobacco companies, competitors in markets, jointly fought back the litigation in Korea. Any litigation against a single local tobacco company may confront legal networks of tobacco companies. As a result, no litigation against tobacco companies in South Korea has been able to win over tobacco companies. International legal support including the development of guidelines of Article 19 of the Framework Convention on Tobacco Control is vital for an effective legal fight against tobacco companies around the world.

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.

Tobacco control in Nepal during a time of government turmoil (1960-2006)

BACKGROUND

Nepal was a monarchy, then a dictatorship, then a democracy. This paper reviews how tobacco control progressed in Nepal in the context of these changes in government from 1950 through 2006.

METHODS

We triangulated tobacco industry documents, newspaper articles and key informant interviews.

RESULTS

Until 1983, the tobacco industry was mostly state owned. Transnational tobacco companies entered the Nepalese market through ventures with Surya Tobacco Company Private Limited (with Imperial Tobacco Company and British American Tobacco) in 1983 and Seti Cigarette Factory Limited (with Philip Morris International [PMI]) in 1985. Seminars and conferences on tobacco, celebrations of World No Tobacco Day (WNTD) and efforts by WHO helped promote tobacco control in Nepal beginning in the 1970s. Tobacco advocates in Nepal pushed the government to issue executive orders banning smoking in public places in 1992 and tobacco advertising in electronic media in 1998, and to introduce a tobacco health tax in 1993. The tobacco industry lobbied against these measures and succeeded in keeping the tobacco tax low by challenging it in court. Tobacco advocates sued the government in 2003 and 2005, resulting in a June 2006 Supreme Court decision upholding the smoking and advertising bans and requiring the government to enact a comprehensive tobacco control law.

CONCLUSIONS

Political instability, conflict, weak governance and the dictatorship significantly affect tobacco control activities in low-income and middle-income countries. Nepal shows that tobacco control advocates can take advantage of global events, such as WNTD, and use domestic litigation to maintain support from civil societies and to advocate for stronger tobacco control policies.

Removing the last billboard for the tobacco industry: Tobacco standardized packaging in Ireland

The World Health Organization's Framework Convention on Tobacco Control (FCTC) implementation guidelines recommend that governments adopt plain packaging (also known as standardized packaging (SP)) along with pictorial health warning labels covering 50% or more of the tobacco package. The 2014 revised European Union Tobacco Product Directive also supports EU member states to introduce SP. Following these developments and recommendations, in 2013 the Department of Health launched a "Tobacco Free Ireland" policy which aimed to reduce the smoking prevalence rate to less than 5% by 2025. Tobacco Free Ireland set out 60 recommendations and measures to reach the 2025 target, including introducing SP. Tobacco companies and trademark and intellectual property organizations opposed the SP proposal claiming it would; 1) not work to reduce smoking levels, 2) increase illicit tobacco trade, 3) create unnecessary problems for retailers, and 4) violate domestic and international laws governing trademarks. However leading health groups in Ireland presented evidence on how SP would communicate the harms of tobacco to smokers and discourage young people from beginning to smoke. These efforts combined with strong political will helped Ireland to become the second country in the world to enact standardized packaging for all tobacco products.

Normalizing Tobacco? The Politics of Trade, Investment, and Tobacco Control

Policy Points Tobacco industry denormalization is a key strategy for tobacco control that has been formalized in the WHO Framework Convention on Tobacco Control. International trade and investment laws are a potential threat to tobacco industry denormalization because they do not automatically incorporate denormalization and, in theory, treat tobacco firms like other commercial interests. Countries that seek to defend tobacco control policies against international trade and investment challenges need to have good governance in two senses: good governance as understood by tribunals and good-enough governance to manage the processes and requirements that enable policies to survive international challenges.

CONTEXT

Tobacco industry denormalization (TID), portraying tobacco product manufacturers as a deadly industry, is a major strategy for public health advocates. Using this strategy, activists around the world have successfully pushed for governments to enact tobacco control regulations, including the unprecedented international Framework Convention on Tobacco Control (FCTC). TID has been a distinctive legal and political strategy that has affected the place of tobacco in law and has both inspired and constrained those who would imitate the strategy in other areas of regulation, such as diet or alcohol. It is therefore a case study in the creation of a distinctive legal approach and of threats to that approach from the changing role of world trade and investment law, which creates a new set of venues that tobacco industry advocates can use to redefine tobacco as a normal good and to seek out "fair and equitable treatment" for their industry.

METHODS

I review legal and policy documents pertaining to two major challenges to tobacco control policies in Australia and Uruguay aimed at controlling industry branding.

FINDINGS

International trade and investment law challenges TID and raises fundamental questions about the role of the state in protecting public health. Recent trade disputes involving Uruguay and Australia illustrate this dynamic. Despite losing high-court challenges against packaging regulations in both countries, tobacco firms were still able to challenge states in a different way, through international trade and investment agreements. This article identifies the industry's strategies and the responses of those seeking to avoid renormalizing tobacco as a part of world trade. In particular, states must demonstrate that their tobacco control policies satisfy standards set by tribunals, which include standards of good governance, and they must prepare their policies in a way that reduces legal risk and requires good governance.

CONCLUSIONS

Although TID has strengthened the hand of tobacco control advocates, TID strategies alone are not sufficient to defend public regulations against extraterritorial legal challenges in an arena that resists the basic TID technique of singling out a particular industry. Public health advocates might also note the FCTC's aid in helping governments defend themselves against these challenges and consider similar international instruments for other areas.

Memoranda of understanding: a tobacco industry strategy to undermine illicit tobacco trade policies

OBJECTIVE

Analyse the transnational tobacco companies' (TTCs) memoranda of understanding (MoUs) on illicit trade and how they could undermine the WHO Framework Convention on Tobacco Control (FCTC) and the Protocol to Eliminate Illicit Trade in Tobacco Products (Protocol).

METHODS

Review of tobacco industry documents and websites, reports, news and media items using standard snowball search methods.

RESULTS

Facing increasing pressure from governments and the FCTC to address illicit tobacco trade during the late 1990s, TTCs entered into voluntary partnerships embodied in MoUs with governments' law enforcement and customs agencies. One of the earliest known MoUs was between Philip Morris International and Italy in 1999. TTCs agreed among themselves to establish MoUs individually but use the Italian MoU as a basis to establish similar connections with other governments to pre-empt more stringent regulation of illicit trade. TTCs report to have signed over 100 MoUs since 1999, and promote them on their websites, in Corporate Social Responsibility reports and in the media as important partnerships to combat illicit tobacco trade. There is no evidence to support TTCs' claims that these MoUs reduce illicit trade. The terms of these MoUs are rarely made public. MoUs are non-transparent partnerships between government agencies and TTCs, violating FCTC Article 5.3 and the Protocol. MoUs are not legally binding so do not create an accountability system or penalties for non-compliance, rendering them ineffective at controlling illicit trade.

CONCLUSION

Governments should reject TTC partnerships through MoUs and instead ratify and implement the FCTC and the Protocol to effectively address illicit trade in tobacco products.

Limited implementation of the framework convention on tobacco control's tobacco tax provision: global comparison

OBJECTIVE

To quantify changes in tobacco tax rates and cigarette affordability after countries ratified the WHO Framework Convention on Tobacco Control (FCTC) using with the WHO MPOWER standards.

METHODS

We used logistic regression to assess the association of FCTC ratification with adoption of at least 50% and 75% (high) of retail price tobacco tax rates for the most sold brands in countries, accounting for years since ratification and other covariates. We also compared cigarette affordability in 2014 with 1999.

RESULTS

By 2014, 44% of high-income countries had taxes above 75% of retail value compared with 18% in 1998/1999. In 15 years, 69 countries increased the tobacco tax rate, 33 decreased it and one had the same tax rate. FCTC ratification was not associated with implementing high tobacco taxes. More fragile countries in terms of security, political, economic and social development were less likely to have at least 50% and 75% tobacco tax rates in 2014 compared with 1999. The higher the cigarette prices in 1999 the less likely the countries were to have at least 75% tobacco tax rates in 2014. However, cigarettes were less affordable in 2014 than in 1999 in countries that had ratified FCTC earlier.

CONCLUSIONS

Despite widespread FCTC ratification, implementing higher tobacco taxes remains incomplete. Guidelines for FCTC Article 6 implementation should assign definite targets for tobacco taxes and for implementation of a tax escalator that gradually increases taxes to match rising income levels. Fragile countries are less likely to have high tobacco taxes and less affordable cigarettes. The tobacco control community should intensify efforts to help fragile countries improve performance in FCTC implementation both through strengthening their administrative and technical capacity and through supporting basic functions of government.

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.

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.

Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group

Objective

To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty’s first decade.

Data sources

Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts.

Study selection

WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies.

Data extraction

Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts.

Data synthesis

Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents.

Conclusions

The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.

Containing diffusion: the tobacco industry's multipronged trade strategy to block tobacco standardised packaging

OBJECTIVE

To analyse the tobacco industry's strategy of using trade and investment agreements to prevent the global diffusion of standardised packaging (SP) of tobacco products.

METHODS

Review of tobacco industry documents, relevant government documents and media items. The data were triangulated and thematically analysed.

RESULTS

Internal tobacco industry documents reveal that during the early 1990s, tobacco companies developed a multipronged trade strategy to prevent the global diffusion of progressive tobacco packaging and labelling proposals, including SP. This strategy consisted of (1) framing the health issue in terms of trade and investment, (2) detailing alleged legal violations concerning trade barriers, intellectual property and investment rights, (3) threatening legal suits and reputational damage, and (4) garnering third-party support. These efforts helped delay SP until 2010 when Australia became the first country to reintroduce SP proposals, followed by governments in the UK and New Zealand in 2012, Ireland in 2013 and France in 2014. Review of government documents and media sources in each of the five countries indicate the industry continues to employ this multipronged strategy throughout the SP policy's progression. Although this strategy is tailored towards each domestic context, the overall tobacco industry's trade strategy remains consistently focused on shifting the attention away from public health and towards the realm of trade and investment with more corporate-friendly allies.

CONCLUSION

Governments seeking to implement SP need to be prepared to resist and counter the industry's multipronged trade strategy by avoiding trade diversions, exposing false industry legal and reputational claims, and monitoring third-party support.

Regulatory chills: tobacco industry legal threats and the politics of tobacco standardised packaging in New Zealand

AIMS

To describe the process of enacting tobacco standardised packaging (SP) amidst tobacco industry legal threats in New Zealand.

METHODS

Relevant government and NGO documents, and media items were reviewed. Policymakers and health advocates in New Zealand were interviewed. The data were triangulated and thematically analysed.

RESULTS

In 2011, the New Zealand Government announced the goal of becoming a smokefree country (reducing smoking prevalence to 5%) by the year 2025, and considered adopting SP. In April 2012, the Government announced it would introduce SP, but tobacco companies threatened the Government with litigation in international courts for violating investment and intellectual property rights. In response, the Government adopted a 'wait and see' approach, waiting until two legal challenges against Australia's SP law were resolved before it enacted its legislation in September 2016. Health advocates, limited due to funding constraints, attempted to alter the Government's approach to the legal threats without success. Interviews with policymakers and health advocates confirmed these threats helped produce a regulatory chill, delaying the policymaking process by three years.

CONCLUSION

The New Zealand case illustrates how the threat of a potential international lawsuit can create a chilling effect by helping delay the implementation of public health policies.

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.

Advancing progressive health policy to reduce NCDs amidst international commercial opposition: Tobacco standardised packaging in Australia

This study examines how health advocates and the Australian government responded to international commercial pressure during the implementation of tobacco standardised packaging (SP) as a measure to reduce non-communicable diseases (NCDs). Relevant government and NGO documents, and media items were reviewed. Policymakers and health advocates (n = 19) in Australia were interviewed. In 2009, Australia's National Health Taskforce recommended SP, which the Australian government announced in April 2010. In response, tobacco companies threatened the government with litigation in both domestic and international courts, claiming that SP would violate their investment and intellectual property rights. However, these legal threats were unsuccessful in forcing the government to withdrawal the SP proposal. Tobacco companies legally challenged SP, but as of February 2018 failed with each legal challenge. The political success of enacting and implementing SP against international commercial pressure was supported by legal preparation and support, and a whole-of-government approach. The Australian SP case illustrates how, against international commercial opposition, governments can build and maintain political and official support to enact and implement progressive public health measures to reduce NCDs.

Avoiding "A Massive Spin-Off Effect in West Africa and Beyond": The Tobacco Industry Stymies Tobacco Control in Nigeria

Background

Nigeria plays important economic and political roles in Africa and is a significant market for the tobacco industry. This study describes the tobacco industry's efforts to block Nigeria's early tobacco control attempts, especially the Tobacco Smoking (Control) Decree 20 of 1990, and efforts to strengthen the Decree in 1995.

Method

Analysis of documents from the Truth Tobacco Documents Library and other Internet resources related to Nigeria's Decree 20 and earlier tobacco control efforts.

Results

The World Conferences on Smoking and Health and World Health Organization in the late 1970s spurred the Nigerian government to take steps towards tobacco regulation. In response, the tobacco industry lobbied government ministries, used front groups and its trade group, the Tobacco Advisory Council of Nigeria, to block and weaken government efforts. The industry obtained a draft of Decree 20 two years before it was enacted, considered the Decree anti-business and proposed language that led to the passage of a weaker Decree in 1990. It also attempted to influence a potential review of the Decree in 1995.

Conclusion

Decree 20 was a strong law for its time, but was weakened due to tobacco industry interference. Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005, and enacted a comprehensive National Tobacco Control Act (NTCA) in May 2015. Lessons learned from Decree 20's experience should be applied to protect NTCA 2015, and in compliance with WHO FCTC Article 5.3 which require parties to protect tobacco control policies from tobacco industry interference.

Implications

This is the first detailed account of tobacco industry interference with tobacco legislation in Africa. The emergence of tobacco control in Nigeria threatened the tobacco industry, which believed that success in Nigeria would have a "domino effect" in Africa. The industry used lobbying and front groups to successfully block and weaken Nigeria's tobacco control, especially the Tobacco Smoking (Control) Decree 20 of 1990 and efforts to strengthen it in 1995. Nigeria and other African countries must learn from this history to protect tobacco control policies from the tobacco industry's vested interests and vigorously implement Article 5.3 of the WHO FCTC.