Tobacco control, global health policy and development: towards policy coherence in global governance

The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.     

International trade agreements: a threat to tobacco control policy

International covenants establish a role for governments in ensuring the conditions for human health and wellbeing, which has been recognised as a central human right. International trade agreements, conversely, prioritize the rights of corporations over health and human rights. International trade agreements are threatening existing tobacco control policies and restrict the possibility of implementing new controls. This situation is unrecognised by many tobacco control advocates in signatory nations, especially those in developing countries. Recent agreements on eliminating various trade restrictions, including those on tobacco, have expanded far beyond simply international movement of goods to include internal tobacco distribution regulations and intellectual property rules regulating advertising and labelling. Our analysis shows that to the extent trade agreements protect the tobacco industry, in itself a deadly enterprise, they erode human rights principles and contribute to ill health. The tobacco industry has used trade policy to undermine effective barriers to tobacco importation. Trade negotiations provide an unwarranted opportunity for the tobacco industry to assert its interests without public scrutiny. Trade agreements provide the industry with additional tools to obstruct control policies in both developed and developing countries and at every level. The health community should become involved in reversing these trends, and help promote additional measures to protect public health.     

The conceptual framework of the International Tobacco Control (ITC) Policy Evaluation Project

This paper describes the conceptual model that underlies the International Tobacco Control Policy Evaluation Project (ITC Project), whose mission is to measure the psychosocial and behavioural impact of key policies of the Framework Convention on Tobacco Control (FCTC) among adult smokers, and in some countries, among adult non-smokers and among youth. The evaluation framework utilises multiple country controls, a longitudinal design, and a pre-specified, theory-driven conceptual model to test hypotheses about the anticipated effects of specific policies. The ITC Project consists of parallel prospective cohort surveys of representative samples of adult smokers currently in nine countries (inhabited by over 45% of the world's smokers), with other countries being added in the future. Collectively, the ITC Surveys constitute the first-ever international cohort study of tobacco use. The conceptual model of the ITC Project draws on the psychosocial and health communication literature and assumes that tobacco control policies influence tobacco related behaviours through a causal chain of psychological events, with some variables more closely related to the policy itself (policy-specific variables) and other variables that are more downstream from the policy, which have been identified by health behaviour and social psychological theories as being important causal precursors of behaviour (psychosocial mediators). We discuss the objectives of the ITC Project and its potential for building the evidence base for the FCTC.     

Building the evidence base for effective tobacco control policies: the International Tobacco Control Policy Evaluation Project (the ITC Project)

The Framework Convention on Tobacco Control (FCTC) is a seminal event in tobacco control and in global health. Scientific evidence guided the creation of the FCTC, and as the treaty moves into its implementation phase, scientific evidence can be used to guide the formulation of evidence-based tobacco control policies. The International Tobacco Control Policy Evaluation Project (ITC Project) is a transdisciplinary international collaboration of tobacco control researchers who have created research studies to evaluate and understand the psychosocial and behavioural impact of FCTC policies as they are implemented in participating ITC countries, which together are inhabited by over 45% of the world's smokers. This introduction to the ITC Project supplement of Tobacco Control presents a brief outline of the ITC Project, including a summary of key findings to date. The overall conceptual model and methodology of the ITC Project--involving representative national cohort surveys created from a common conceptual model, with common methods and measures across countries--may hold promise as a useful paradigm in efforts to evaluate and understand the impact of population-based interventions in other important domains of health, such as obesity.     

Human rights-based approach to tobacco control

The Framework Convention for Tobacco Control (FCTC) is currently the most potent tool for implementation of tobacco control laws across the globe. The FCTC is derivative from previously constructed international human rights conventions. These previous conventions have enforcement mechanisms, unlike the FCTC. However, the FCTC relies on state parties to report periodically on its implementation rather than on a continuous monitoring system. The Human Rights and Tobacco Control Network proposes that abiding by the principles of human rights delineated by international treaties, citizens across the globe can demand effective action for tobacco control. This paper explains the link between fundamental human rights and the right to tobacco control. Mechanisms are described to link the FCTC and its principles with human rights-based monitoring reports, which are provided to oversight committees for the other human rights conventions. The initial work of the Human Rights and Tobacco Control Network is summarised and considers the future directions for the human rights-based approach to tobacco control.     

Achieving the Framework Convention on Tobacco Control's potential by investing in national capacity

May 2003 marked a critical achievement in efforts to stem the global tobacco epidemic, as the member states of the World Health Organization unanimously endorsed the Framework Convention on Tobacco Control (FCTC). However, the adoption of the FCTC signifies only the end of the beginning of effective global action to control tobacco. Over the next several years the utility of the FCTC process and the treaty itself will be tested as individual countries seek to ratify and implement the treaty's obligations. Significant barriers to the treaty's long term success exist in many countries. It is crucial that the international tobacco control community now refocuses its efforts on national capacity building and ensures that individual countries have the knowledge, tools, data, people, and organisations needed to implement the convention and develop sustained tobacco control programmes. This paper provides a model of national tobacco control capacity and offers a prioritised agenda for action.     

Food smuggling and trafficking: The key factors of influence

BackgroundFood smuggling and food trafficking are terms not currently defined in the food literature. This work sought to determine how such definitions could be developed in order to inform future research and surveillance activity.Scope and approachThe concept of food smuggling and food trafficking is considered, and regulatory food surveillance data for illegal and unauthorised imports and food trade incidents (n = 347) into the European Union (EU) between 1987 and 2017 is explored and critiqued.Key findingsIllegal imports, especially animal and fish products, can pose a threat to human and animal health, spread animal disease and invasive plant species, and lead to loss of wildlife and biodiversity. Economies are weakened through the tax avoidance and evasion elements of food smuggling and coercive food trafficking. Reported illegal trade in the EU's Risk Assessment for Food and Feed (RASFF) database was highest for meat products followed by fruit and vegetables. Purposive sampling means the data does not reflect the true incidence, extent and type of illegal imports especially by individuals for personal use. There are limited global strategies in place to address food smuggling and trafficking. This work has translated the lessons learnt from the processes developed to reduce tobacco smuggling to illicit activity associated with food. Elements of a comprehensive strategy to address illicit food trade include the developing of effective legal and institutional frameworks in association with effective, transparent communication and cooperation systems. This paper fills a current gap in the academic literature on this topic.     

Four COPs and counting: achievements, underachievements and looming challenges in the early life of the WHO FCTC Conference of the Parties

As the governing body of the WHO Framework Convention on Tobacco Control (FCTC), the Conference of the Parties (COP) is mandated to 'keep under regular review the implementation of the Convention and take the decisions necessary to promote its effective implementation'. The COP has a range of critical roles to play spanning the setting of normative standards, the building and dissemination of knowledge, the monitoring of implementation, the facilitation of international cooperation and the mobilisation of resources to support implementation. The COP has met four times to date. It has made significant achievements in the setting of normative standards, with the adoption of a number of high-standard implementation guidelines and a declaration recording the commitment of Parties to prioritise the implementation of health measures in the context of concerns about the effect of international trade and investment obligations. Less progress has been made in other areas, including a general lack of support for the conduct of needs assessments by developing countries-though needs assessments have been designated as a prerequisite to the mobilisation of funding support-and a reluctance to consider the adoption of a robust system of implementation review. Much remains to be done to build the FCTC's implementation support structure. Other looming challenges include maintaining the voice and influence of developing countries against priorities being overly dictated by wealthier Parties and in the face of recent cutbacks to travel support pushed by the European Union, and managing the likely resource demands and other risks of the proposed illicit trade protocol.     

对烟草认知与履行公约实际边界关系的研究

为正确引导不同文化身份人群认知《公约》并正确履约,分析了在履行《烟草控制框架公约》进程中出现的认知差异,不同的烟草发展历史区隔出履约的实际边界;从对烟草的文化认知,特别是从企业性质及其内在规定性等角度,系统解析了烟草企业与其社会责任的辩证关系,对烟草社会责任认识矛盾的根源是对烟草客观存在认识的矛盾,认知的客观差异将影响《公约》实际边界的形成。通过对烟草承担社会责任的现实观察,明确了烟草企业履行社会责任与履行公约义务不存在根本的矛盾。     

Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union-part II: an overview of priorities and tactics used to establish a manufacturing presence

Objectives: To explore how British American Tobacco (BAT), having established cigarette imports, responded to the opportunities for investment in cigarette manufacturing in the former Soviet Union (FSU).

Design: Analysis of documents held at the BAT archive in Guildford, UK.

Results: Considerable priority was attached to investing in the FSU. This led BAT to undertake a major organisational change and to intense competition to acquire assets. BAT used flawed economic arguments to persuade cash starved governments that its investment would reap economic rewards. It offered excise advice that disadvantaged governments while benefiting BAT, confused issues over pricing, and avoided competitive tendering. BAT targeted agriculture ministries, using its expertise in leaf production to differentiate itself from other potential investors. It subverted the principles of corporate social responsibility to promote itself as a business partner. BAT's task was made easier by the naivety of post-Soviet governments and by the international financial organisations' support for rapid economic reform. The latter permitted tobacco transnationals to penetrate markets before effective competitive tendering processes had been established, giving them the opportunity to minimise prices and establish monopolies.

Conclusions: Many of the arguments employed when penetrating post-Soviet markets were highly misleading but governments lacked expertise to realise this. There is a need to build tobacco control capacity in transition economies, within and outside government, to ensure that governments are better informed of the true economic and health impacts of tobacco. Rapid transition from socialist to market economies without establishing regulatory institutional structures may be dangerous when investing companies use business practices that fall short of international standards.

     

Implementation of the WHO Framework Convention on Tobacco Control in mainland China

As per China's ratification of the WHO Framework Convention on Tobacco Control (FCTC), it should have implemented effective packaging and labelling measures prior to 9 January 2009 and enacted a comprehensive ban on all tobacco advertising, promotion and sponsorship prior to 9 January 2011. In addition, universal protection against secondhand tobacco smoke should have been implemented before 9 January 2011 by ensuring that all indoor workplaces, all indoor public places, all public transportation and possibly other (outdoor or quasi-outdoor) public places are free of secondhand smoke. The authors conducted a review of various sources of information to determine the current status of FCTC implementation in mainland China. Even though China has made considerable efforts to implement the FCTC, there is still a significant gap between the current state of affairs in China and the requirements of the FCTC. The Chinese tobacco monopoly under which commercial and other vested interests of the tobacco industry are jeopardizing tobacco control efforts is thought to be the most crucial obstacle to the effective implementation of the FCTC across the country.     

《烟草控制框架公约》研究Ⅱ.主要內容、对烟草业的影响和需采取的措施

文章在对"吸烟与健康"的早期研究、世界卫生组织烟草控制的历史,以及《烟草控制框架公约》的制定过程进行了简要回顾的基础上(见本文第1部分),全面概括了其主要内容,并就其对烟草业的影响进行分析,探讨了在未来履行公约具体义务的过程中,烟草业可采取的有关应对措施。      

烟草制品包装和标签履约情况综述及对我国卷烟包装影响的思考

综述了相关国家烟草制品包装和标签履约动态,介绍了已经实施图片健康警告的国家和地区图片警示标签使用情况,以及有关烟草制品包装和标签问题的学术研究,提出了公约履约对我国卷烟包装影响的思考.     

Cigarette smuggling in Europe: who really benefits?

Cigarette smuggling, now on the increase, is so widespread and well organised that it poses a serious threat to public health. This threat comes from two principal directions. First, smuggling makes cigarettes available cheaply, thereby increasing consumption. A third of annual global exports go to the contraband market, representing an enormous impact on consumption, and thus causing an increase in the burden of disease, especially in poorer countries. It is also costing government treasuries thousands of millions of dollars in lost tax revenue. Second, the tobacco industry uses smuggling politically, lobbying governments to lower tax, arguing that smuggling is caused by price differences. This paper shows that the claimed correlation between high prices and high levels of smuggling does not exist in western Europe. In fact, countries such as Norway and Sweden, with expensive cigarettes, do not have a large smuggling problem, whereas countries in the south of Europe do. Cigarette smuggling is not caused principally by "market forces". It is mainly caused by fraud, by the illegal evasion of import duty. The cigarettes involved are not the cheap brands from southern European countries, for which there is no international market. It is the well-known international brands such as Marlboro and Winston. We propose much tighter regulation of cigarette trade, including an international transport convention, and a total ban on transit trade—sale by the manufacturers to dealers, who sell on to smugglers.

     

中国烟草重税政策对增加政府收入和减少烟草消费的影响

从历史的角度阐述了政府对烟草产品长期实行重税政策在增加政府收入中做出的重要贡献,分析了政府对烟草产品征收重税的基本理由是增加政府收入和减少烟草消费,找出了在减少烟草消费方面效果并不明显的原因,主要是烟草税收对各级政府的内在激励、卷烟价格结构的多层次性和卷烟承载的社会交往功能。      

Current situation and future challenges of tobacco control policy in Thailand

In Thailand, the prevalence of smoking has steadily declined over the past 20 years, suggesting an effective tobacco control policy. However, the prevalence has recently stabilised and youth smoking now appears to be on the rise. Tobacco use is the third highest risk factor contributing to the burden of disease in the country. This is an issue of concern and led to the present review of tobacco control measures in Thailand. The present evidence-based review shows that Thailand's tobacco control measures are relatively strong and comply well with the WHO Framework Convention on Tobacco Control in terms of taxation, advertisement through popular media, and warning labels on cigarettes and other tobacco product packages. However, challenges remain in dealing with highly prevalent roll-your-own cigarettes, strict prohibition of tobacco sale to underage youths, household smoking, illicit trade of tobacco products, viable tobacco crop diversification for domestic tobacco growers and liability. If these challenges are met, the prevalence of tobacco consumption could possibly be further reduced.     

中国烟业 别被FCTC撞了腰

<正> 在日内瓦举行的世界卫生大会上,世卫组织(WHO)的192个成员国5月21日一致通过了第一个限制烟草的全球性条约——《烟草控制框架公约》(FCTC),其总干事布伦特兰女士把这天称为“历史性的日子”。 自20世纪80年代末以来,几乎每年的世界卫生大会都有关于控烟工作的决议。但直至FCTC的出现,全球烟草业才感受到真正的威胁。     

Building capacity for tobacco control research and policy

The Fogarty International Center (FIC) initiative, "International Tobacco and Health Research Capacity Building Program" represents an important step in US government funding for global tobacco control. Low- and middle-income countries of the world face a rising threat to public health from the rapidly escalating epidemic of tobacco use. Many are now parties to the Framework Convention on Tobacco Control (FCTC) and capacity development to meet FCTC provisions. One initial grant provided through the FIC was to the Institute for Global Tobacco Control (IGTC) at the Johns Hopkins Bloomberg School of Public Health (JHSPH) to support capacity building and research programmes in China, Brazil, and Mexico. The initiative's capacity building effort focused on: (1) building the evidence base for tobacco control, (2) expanding the infrastructure of each country to deliver tobacco control, and (3) developing the next generation of leaders as well as encouraging networking throughout the country and with neighbouring countries. This paper describes the approach taken and the research foci, as well some of the main outcomes and some identified challenges posed by the effort. Individual research papers are in progress to provide more in-depth reporting of study results.     

Uneasy money: the Instituto Carlos Slim de la Salud, tobacco philanthropy and conflict of interest in global health

In May 2007, the Instituto Carso de la Salud-now Instituto Carlos Slim de la Salud (ICSS)-was endowed with US$500 million to focus on priority health issues in Latin America, notably issues of 'globalisation and non-communicable diseases'. ICSS was soon criticised, however, on the grounds that its funding was derived from tobacco industry profits and that its founder Carlos Slim Hélu remained an active industry principal. Collaboration with ICSS was said to run counter to the WHO Framework Convention on Tobacco Control. The Institute's then Executive President Julio Frenk disputed these charges. This research employs an archive of tobacco industry documents triangulated with materials from commercial, media, regulatory and NGO sources to examine the financial relations between Slim and the tobacco industry. The paper analyses Slim's continuing service to the industry and role in ICSS. It demonstrates a prima facie conflict of interest between ICSS's health mission and its founder's involvement in cigarette manufacturing and marketing, reflected on ICSS's website as a resounding silence on issues of tobacco and health. It is concluded that the reliance of international health agencies upon the commercial sector requires more robust institutional policies to effectively regulate conflicts of interest.     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.