'A contradiction between our state and the tobacco company': conflicts of interest and institutional constraints as barriers to implementing Article 5.3 in Bangladesh

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

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

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.

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.

Framing health taxes: learning from low- and middle-income countries

Health taxes are effective policy instruments to save lives, raise government revenues and improve equity. Health taxes, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy. Yet, little is known about which frames resonate in which settings and how framing can most effectively advance or limit policies. To fill this gap, we conducted qualitative research in 2022, including focus group discussions, in-depth interviews, document reviews and media analysis on the political economy of health taxes across eight low-income and middle-income countries. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Findings suggest that no single frame dominates; in fact, a plurality of different frames exist and shape discourse and policymaking. There was no clear trade-off between health and economic framing of health tax policy proposals, nor a straightforward way to handle concerns around earmarking. Understanding how to best position health taxes can empower health policymakers with more persuasive framings for health taxes and can support them to develop broader coalitions to advance health taxes. These insights can improve efforts to advance health taxes by better appreciating political economy factors and constraining corporate power, ultimately leading to improved population-level health.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND AND OBJECTIVES

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

METHOD

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

RESULT

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

CONCLUSION

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

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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