Integrating tobacco control into health and development agendas

Tobacco use is one of the major risk factors for non-communicable diseases, with a profound impact on resource-poor low-income and middle-income countries such as India, where tobacco use is high and where socioeconomic as well as health inequalities are rampant. Effective implementation of the Framework Convention on Tobacco Control requires multisectoral efforts that can fructify through integration of tobacco control into broader health and development agendas such as food and water security, environment, the right to education and human rights. The global tobacco control community will need to explore innovative partnerships beyond its traditional confines and build a global coalition that supports tobacco control by partnering with others having convergent concerns on common determinants. A firm political commitment and intersectoral coordination between government and non-government agencies is paramount in order to implement effective tobacco control programmes. Integration of tobacco control into other health and development agendas as described in this paper has the potential to contribute to the achievement of all the eight United Nations Millennium Development Goals. This paper explores why the whole of government should accord a high priority to tobacco control, and how this integration could be achieved.     

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.     

African American leadership groups: smoking with the enemy

BACKGROUND: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown. OBJECTIVE: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. METHODS: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. RESULTS: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. CONCLUSION: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.     

Understanding Philip Morris's pursuit of US government regulation of tobacco

Objective: To investigate Philip Morris's support of US Food and Drug Administration (FDA) regulation of tobacco products and analyse its relationship to the company's image enhancement strategies.

Data sources: Internal Philip Morris documents released as part of the Master Settlement Agreement.

Methods: Searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) beginning with such terms as "FDA" and "regulatory strategy" and expanding to include relevant new terms.

Results: Philip Morris's support for government regulation of tobacco is part of a broader effort to address its negative public image, which has a damaging impact on the company's stock price, political influence, and employee morale. Through regulation, the company seeks to enhance its legitimacy, redefine itself as socially responsible, and alter the litigation environment. Whereas health advocates frame tobacco use as a public health policy issue, Philip Morris's regulatory efforts focus on framing tobacco use as an individual choice by informed adults to use a risky product. This framing allows Philip Morris to portray itself as a reasonable and responsible manufacturer and marketer of risky products.

Conclusions: Philip Morris's ability to improve its image through support of FDA regulation may undermine tobacco control efforts aimed at delegitimising the tobacco industry. It may also create the impression that Philip Morris's products are being made safer and ultimately protect the company from litigation. While strong regulation of tobacco products and promotion remain critical public health goals, previous experiences with tobacco regulation show that caution may be warranted.

     

Individual rights advocacy in tobacco control policies: an assessment and recommendation

Efforts to control environmental tobacco smoke (ETS) could be assisted if the tobacco control movement gave greater emphasis to the issue of individual rights. Benefits that may accrue from the promotion of a clear individual rights perspective in tobacco control include adding coherence to the tobacco control advocacy agenda and winning support from those who may have been concerned about loss of personal freedom, excessive governmental power, use of social coercion, or the rights of smokers. Risks also attend to such a policy. It might inadvertently assist the tobacco industry, stir resistance to ETS limitation efforts, or confuse tobacco control supporters. On balance, though, liabilities are outweighed by the ethical and operational merits in tobacco control of a heightened pro-individual rights stance.     

Social movements and human rights rhetoric in tobacco control

After achieving breathtaking successes in securing state and local restrictions on smoking in public places and restricting youth access to tobacco products, the tobacco movement faces difficult decisions on its future strategic directions. The thesis of this article is that the tobacco control movement is at a point of needing to secure its recent successes and avoiding any public retrenchment. To do so requires rethinking the movement's strategic direction. We use the familiar trans-theoretical model of change to describe where the movement is currently and the threats it faces. The new tobacco control strategy should encompass a focus on voluntary non-smoking strategies, use human rights rhetoric to its advantage, and strengthen the public health voice to be more effective in political battles. In developing a new strategy, tobacco control advocates need to build a social movement based on a more forceful public health voice, along with the strategic use of human rights rhetoric, to focus on the power of voluntary non-smoking efforts. Using human rights rhetoric can help frame the movement in ways that have traditionally appealed to the American public. Perhaps more importantly, doing so can help infuse the tobacco control movement with a broader sense of purpose and mission.     

Taking it to the streets: responses of African American young adults to internal tobacco industry documents.

Since the Master Settlement Agreement of 1998 between 46 states and the major tobacco companies forced the release of over 30 million pages of previously secret internal tobacco industry documents, researchers have been exploring how information in the documents can be useful for advancing public health efforts. Previous research shows that the tobacco industry has made massive efforts to target marginalized communities, not only through typical advertising channels but also through establishing financial and other ties with influential leadership groups. However, no previous studies have explored how members of targeted groups might respond at the grassroots level to actual internal tobacco industry documents about such targeting. This exploratory focus group study, which invited urban African American participants to comment on previously secret internal tobacco industry documents, suggests that such documents may be useful in efforts to socially denormalize tobacco use, promote critical reflection about community targeting, and mobilize individuals toward quitting.     

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.     

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.

     

Tobacco industry strategies to undermine the 8th World Conference on Tobacco or Health

Objective: To demonstrate that Philip Morris and British American Tobacco Company attempted to initiate a wide ranging campaign to undermine the success of the 8th World Conference on Tobacco or Health held in Buenos Aires, Argentina, in 1992.

Data sources: Publicly available tobacco industry documents housed in Minneapolis, Minnesota, USA; Guilford, UK; on-line document websites; and telephone interviews with informed parties.

Study selection: Those documents determined to be relevant to the companies' campaigns against the 8th World Conference on Tobacco or Health.

Data extraction: Revision of chapter VIII of the July 2000 WHO report by a committee of experts, entitled: Tobacco company strategies to undermine tobacco control activities at the World Health Organization: report of the committee of experts on tobacco industry documents.

Data synthesis: Internal documents describe proposed media and science orientated campaigns developed by BAT, Philip Morris, and their consultants to divert attention away from the conference.

Results and conclusion: This work shows that the tobacco industry has the resources and vested interest to combat perceived threats in its regional operating markets, in this case its Latin American market. It is important for the worldwide public heath community to become aware of the numerous ways in which the tobacco industry and its front groups can work against international tobacco control meetings, even including the manipulation of or working with other public health groups to oppose tobacco control efforts. Future world conference planners and participants should be aware that the tobacco industry is likely to continue to employ such methodology. There is no reason to think that the industry is paying less attention to such conferences in the present or future. Rather, it is likely the industry will adopt and expand strategies that were successful while abandoning those that were not effective. Required disclosure of financial support by all participants at all tobacco scientific conferences is recommended. For the tobacco control community, we also recommend careful coalition building and networking with other public health groups on the ways tobacco is implicated in other public health issues.

     

Fiscal versus social responsibility: how Philip Morris shaped the public funds divestment debate

Calls for institutional investors to divest (sell off) tobacco stocks threaten the industry's share values, publicise its bad behaviour, and label it as a politically unacceptable ally. US tobacco control advocates began urging government investment and pension funds to divest as a matter of responsible social policy in 1990. Following the initiation of Medicaid recovery lawsuits in 1994, advocates highlighted the contradictions between state justice departments suing the industry, and state health departments expanding tobacco control programmes, while state treasurers invested in tobacco companies. Philip Morris (PM), the most exposed US company, led the divestment opposition, consistently framing the issue as one of responsible fiscal policy. It insisted that funds had to be managed for the exclusive interest of beneficiaries, not the public at large, and for high share returns above all. This paper uses tobacco industry documents to show how PM sought to frame both the rhetorical contents and the legal contexts of the divestment debate. While tobacco stock divestment was eventually limited to only seven (but highly visible) states, US advocates focused public attention on the issue in at least 18 others plus various local jurisdictions. This added to ongoing, effective campaigns to denormalise and delegitimise the tobacco industry, dividing it from key allies. Divestment as a delegitimisation tool could have both advantages and disadvantages as a tobacco control strategy in other countries.     

The tobacco settlement: an analysis of newspaper coverage of a national policy debate, 1997-98

OBJECTIVE: To examine the framing of tobacco policy issues in the news media during the national tobacco settlement debate of 1997-98. The major aims were (1) to describe the extent of newspaper coverage of each of the specific components of the proposed tobacco settlement; (2) to identify the tobacco control frames, and the dominant frame, appearing in each newspaper article; and (3) to examine trends in tobacco control frames over time. DESIGN: A content analysis was performed on 117 articles related to national tobacco legislation appearing in the Washington Post from 1 January 1997 through 18 June 1998. MAIN OUTCOME MEASURES: (1) Major policy themes of the settlement referred to or implied in each article; (2) major frames used to discuss the problem of tobacco in each article. RESULTS: The generation of new revenue was the dominant theme of the articles, appearing as a major focus in 44% (52) of the articles. Other than the issues of Food and Drug Administration regulation of tobacco and restrictions on cigarette advertising, the public health policy aspects of the tobacco settlement received little attention. The problem of tobacco was portrayed as one of youth smoking in 55% (64) of the articles, but as one of a deadly product in none of the articles. CONCLUSIONS: Future discussions of comprehensive tobacco policy should be driven by a more specific discussion of the precise programme and policy mechanisms by which tobacco use can be most effectively prevented and controlled. The public health community must find ways to frame the tobacco issue more broadly than simply as one of youth smoking.     

Tobacco industry successfully prevented tobacco control legislation in Argentina

Objective: To evaluate how transnational tobacco companies, working through their local affiliates, influenced tobacco control policymaking in Argentina between 1966 and 2005. Methods: Analysis of internal tobacco industry documents, local newspapers and magazines, internet resources, bills from the Argentinean National Congress Library, and interviews with key individuals in Argentina. Results: Transnational tobacco companies (Philip Morris International, British American Tobacco, Lorillard, and RJ Reynolds International) have been actively influencing public health policymaking in Argentina since the early 1970s. As in other countries, in 1977 the tobacco industry created a weak voluntary self regulating code to avoid strong legislated restrictions on advertising. In addition to direct lobbying by the tobacco companies, these efforts involved use of third party allies, public relations campaigns, and scientific and medical consultants. During the 1980s and 1990s efforts to pass comprehensive tobacco control legislation intensified, but the organised tobacco industry prevented its enactment. There has been no national activity to decrease exposure to secondhand smoke. Conclusions: The tobacco industry, working through its local subsidiaries, has subverted meaningful tobacco control legislation in Argentina using the same strategies as in the USA and other countries. As a result, tobacco control in Argentina remains governed by a national law that is weak and restricted in its scope.     

Courtesy and the challenges of implementing smoke-free policies in Japan.

For decades, the tobacco companies have developed a worldwide campaign to oppose the creation of smoke-free environments. Public health efforts to promote clean indoor air have been uneven throughout the world, and in few places have such efforts faced as many challenges as in Japan. The Japanese market is dominated by Japan Tobacco, which is partly owned by the government, and Philip Morris International is also present in Japan. Japan Tobacco and Philip Morris International have developed campaigns promoting courtesy and tolerance that, until recently, seem to have resonated well with the public. The companies also have supported research promoting ventilation and have funded consultants to act as experts in the area of second-hand smoke exposure. Japan is a critical country to study, partly because of the strength of Japan Tobacco in the country and the growth of Japan Tobacco International in Southeast Asia and the rest of the world, and partly because of Japan's ratification of the World Health Organization Framework Convention on Tobacco Control. This paper uses tobacco industry documents to provide an overview of the tobacco industry's scientific and political efforts to stifle the development of clean indoor measures in Japan. Learning past industry strategies may assist policymakers and advocates in the development of future public health activities.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

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.     

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti- tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.


     

Playing hide-and-seek with the tobacco industry.

Despite many peer-reviewed works that draw on tobacco industry documents that have now been made public, questions remain about how complete a picture has emerged. We present a conceptual framework that identifies and evaluates tobacco industry efforts to conceal information. Widespread document destruction like that in recent litigation in Australia is just one of more than a dozen tobacco industry efforts to prevent access, or at least timely access, to documents. Industry efforts range from small, locally employed initiatives to company-wide tactics. Some efforts, such as using "oral only" procedures, scrambling telephone lines, or involving lawyers in scientific projects, are preemptive. Others seek to deal with already existing documents by invoking bogus claims of legal privilege, stipulating "read then destroy" for memos, and rewriting problematic memos. That evidence of concealment has, in fact, been found in tobacco company archives attests to the futility of attempting to control the flow of millions of pieces of paper among tens of thousands of employees. However, researchers have yet to reveal the full story: We know of the industry's failures in concealing information, but not its successes. The industry's objective is not destruction of information per se, but prevention of public disclosure of that information. Exposing the tobacco industry's many approaches to concealment provides greater insight into companies' intentions and potential means for stripping away that concealment.     

Lessons from the history of tobacco harm reduction: The National Cancer Institute's Smoking and Health Program and the "less hazardous cigarette".

Scientists and public health practitioners are sharply divided today over the risks and benefits of tobacco harm-reduction strategies. At the same time, a range of novel tobacco products is being marketed with claims of reduced exposure or risk. Current scientific efforts to study tobacco products and harm reduction should be informed by past experience. During the 1960s and 1970s, there was substantial support within government and academia, as well as among voluntary health organizations, for efforts to modify tobacco products to reduce harm. This paper analyzes the former National Cancer Institute (NCI) Smoking and Health Program, which, between 1968 and 1980, pursued the development of "less hazardous" cigarettes as its primary goal. During this period, the program spent over dollar 50 million on contract research, of which 74% went toward biological and chemical analysis of modified cigarettes, 9.6% to epidemiological studies of risk factors, and only 1.4% to studies evaluating smoking cessation or prevention programs. NCI officials predicted during the mid-1970s that new "low-tar" cigarette brands would substantially reduce smoking-related mortality, but by 1978 the research agenda began to change in response to a reorganization of NCI research activities, modification of government antismoking efforts, and an emerging understanding of nicotine addiction that challenged key scientific assumptions. In retrospect, the program suffered from significant weaknesses that severely limited the likelihood that it would generate knowledge beneficial to public health, including a research agenda that failed to include surveillance and behavioral research, tobacco industry influence of the research agenda, and a lack of access to information about the characteristics of products on the market. There exists today a need for a public health-oriented research agenda on tobacco products and harm reduction, but current efforts should include input from a diverse range of disciplines, collect data on users' behavior, and limit the involvement of industry scientists.     

The human rights responsibilities of multinational tobacco companies

This article explores various strategies which could be used to hold the tobacco industry accountable for human rights violations precipitated by its conduct. First, a brief overview of the international human rights regime and the tobacco related jurisprudence issued by human rights treaty bodies is provided. The article then explains how tobacco control advocates could promote more systematic consideration of governments' tobacco related human rights violations by reconceptualising the Framework Convention on Tobacco Control in the language of rights. The feasibility of using the existing human rights framework to target the tobacco industry directly is analysed with the conclusion that this approach has serious limitations. Emerging human rights norms, which have greater potential to affect the industry's conduct, are presented. Finally, given the questionable authoritativeness of these norms, alternative ways that they could be employed to hold tobacco companies accountable for the rights related consequences of their activities are proposed.