South Asia's evolving tobacco hydra: moving from quandary to hope.

The South Asian region occupies a unique place in global tobacco control because of a broad spectrum of widely used tobacco products and the consequent mix of local and transnational tobacco industries. Cigarette use is especially high among males in many countries, while bidis are widely used in India, Bangladesh and Sri Lanka, and are very inexpensive. Smokeless tobacco use is a global problem, but the bulk of use is in South Asia and there is emerging promotion of newly developed tobacco and nicotine products across the region. With the transnational cigarette industry contributing a significant amount in taxes, the bidi industry employing millions of workers and many farmers engaged in tobacco farming, the industry is powerful and exploits this when countering proposed advancements in tobacco control policy. Despite industry interference and major challenges, this region has achieved remarkable successes in tobacco control, including large pictorial warnings that cover up to 80%-90% of the pack in some countries, stringent rules on depiction of tobacco in movies, bans on advertising and promotion, and smoke-free public places. Key challenges include increasing the tax component of retail prices and reducing tax concessions, regulating newly developed products and countering the aggressive tactics of the tobacco industry. Strategies to advance tobacco control in the region may also include standardised packaging of tobacco products, sustained mass media campaigns to warn the population of the harms of tobacco use and promote use of available cost-covered cessation services, and supply-side measures such as vendor licensing.

Tobacco control in Asia-Pacific: wins, challenges and targets.

For many decades, the international tobacco industry has set its sights on Asia, due to the large population numbers, the high prevalence of male smokers who might shift to its brands, and the extremely low number of female smokers who could possibly be induced into starting smoking. Because of US trade threats against several Asian countries in the 1980s, Asia became quickly aware that tobacco control involved politics, legislation, economics and trade. Several Asian jurisdictions pioneered tobacco control measures, and the Western Pacific is still the only WHO region where all countries have ratified the WHO Framework Convention on Tobacco Control (FCTC). Progress needs to be accelerated to reduce the still high male smoking prevalence and maintain the low female prevalence by fully implementing the WHO FCTC as part of achieving sustainable development, even while grappling with the looming epidemic of new products, holding the companies accountable, and protecting tobacco control policies against constant industry interference.

Tobacco Control Stakeholder Perspectives on the Future of Tobacco Marketing Regulation in Indonesia: A Modified Delphi Study.

OBJECTIVES: Tobacco control in Indonesia is very lenient compared to international standards. This study explored the perspectives of tobacco control stakeholders (TCSs) on the likelihood of advancing tobacco marketing regulation in Indonesia. METHODS: Data were collected from TCSs who were members of the Indonesia Tobacco Control Network group in a modified Delphi study. We collected the data in 2 waves using a questionnaire that comprised a set of closed and open-ended questions. For this paper, we analysed 2 of the 3 sections of the questionnaire: (1) tobacco advertising, promotions, and sponsorship (TAPS) bans, and (2) marketing and retailing regulations. We conducted a descriptive analysis of the scores using Stata/IC.13 and summarised the comments for each item. RESULTS: The TCSs viewed the measures/strategies across all aspects of TAPS and tobacco marketing regulation as highly desirable, but provided varied responses on their feasibility. They rated political feasibility lower than technical feasibility for most measures. Advancing TAPS measures and prohibition of selling to minors were considered more attainable by sub-national governments, while prohibition of tobacco corporate social responsibility was considered as the least feasible measure in the next 5 years. CONCLUSIONS: Despite little optimism for substantial national-level change, there is a positive expectation that sub-national governments will strengthen their tobacco control regulation. It is paramount that the government reduce tobacco industry leverage by implementing Article 5.3 of the World Health Organization Framework Convention on Tobacco Control. Extending advocacy networks beyond tobacco control groups and framing tobacco control more effectively are necessary steps.

Why is tobacco control progress in Indonesia stalled? - a qualitative analysis of interviews with tobacco control experts.

BACKGROUND: Indonesia shoulders a significant tobacco burden, with almost two million cases of tobacco-related illnesses and more than two hundred thousand tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Indonesia from the perspective of tobacco control experts (TCEs). METHOD: We conducted qualitative interviews with four international and ten national TCEs, who have been active in tobacco control for at least 5 years. Our interview guideline included questions on the current tobacco control situation in Indonesia and explored reasons why tobacco control is progressing so slowly. The interviews were conducted either in English or Bahasa Indonesia, recorded and then transcribed verbatim. We conducted a thematic analysis based on five core causal factors for policy adoption: institutions, networks, socio-economic factors, agendas and ideas. RESULTS: The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex bureaucracy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health also contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco control as a sovereignty threat. There is an imbalance of power and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco control networks. The policy agenda is likely influenced by the privileged position of tobacco in Indonesia as a socially acceptable product with high consumption. There are constraints on transferring ideas and evidence to successful policy adoption. CONCLUSION: Tobacco companies have substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the government system and broader networks. Acceding to and enforcing the World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and embrace other community groups to improve engagement and communication with policymakers.

Raising generation 'A': a case study of millennial tobacco company marketing in Indonesia.

OBJECTIVE: To describe the Sampoerna A [A] brand marketing techniques and practices and how event-based sponsorship leverages company websites and popular social media channels to reach and engage young people. METHOD: This case study was built from three main data sources. First, HM Sampoerna company reports, corporate websites and other online sources were reviewed. Second, four pairs of observers conducted an observation survey; systematically auditing and documenting tobacco promotion and advertising at the 2016 SoundrenAline concert. Finally, social media data were obtained from an iterative search of hashtags of Instagram posts. The 10 most frequently used hashtags related to the concert were reviewed and documented. RESULTS: A brand marketing includes sponsorship of a music concert series, a limited edition A Mild cigarette package and promotion of virtual events on company websites and social media channels. Instagram boosted promotion with more than 25 000 posts for the two most popular hashtags endorsed during the concerts. Marketing activities targeted young people by focusing on creativity, freedom of expression and audience engagement. The corporate website 'goaheadpeople.id' served as both a promotional medium and online community. CONCLUSION: Internet and social media channels are key to Sampoerna's marketing strategy in Indonesia. Internet-based marketing run alongside conventional advertising likely increases Indonesian youth exposure to cigarette marketing. This case study also provides evidence that Sampoerna evaded current tobacco advertising regulations. Subnational governments can play a stronger role in restricting tobacco advertising, promotion and sponsorship by more effectively enforcing current regulation.

Tobacco industry interference: A review of three South East Asian countries.

BACKGROUND: The WHO Framework Convention on Tobacco Control (FCTC) Article 5.3 requires governments to protect tobacco control policies from the commercial interest of the tobacco industry (TI). TI interference is the biggest barrier to implementing comprehensive tobacco control measures. OBJECTIVE: This paper reviews the extent of the TI's interference in tobacco control policy development in three countries, Thailand, Myanmar, and Indonesia, and the governments' efforts to protect these policies. METHODS: The paper draws on incidents of TI interference reported in the 2016 Tobacco Industry Interference Index: ASEAN Report on Implementation of the WHO FCTC Article 5.3. Base data were obtained through a questionnaire on twenty most commonly reported incidents of interference from the FCTC Article 5.3 Guidelines recommendations. A scoring system was developed. RESULTS: All three countries faced varying levels of TI interference. Thailand, though known for its stringent tobacco control measures, still faced interference while Myanmar remains vulnerable. Indonesia faced the highest industry interference which may explain why it is lagging behind in tobacco control and remains a nonparty to the WHO FCTC. The TI gains access to government officials through offers of technical assistance and its corporate social responsibility activities. Transparency in dealing with the TI is needed in all three countries. Most governments have not set up disclosure procedures when dealing with the TI. CONCLUSION: Outside the Department/Ministry of Health, other departments remain unaware of Article 5.3, not utilizing its strength to regulate the TI. More concerted effort is needed to implement Article 5.3 to achieve greater success in tobacco control.

SEATCA Tobacco Industry Interference Index: a tool for measuring implementation of WHO Framework Convention on Tobacco Control Article 5.3.

OBJECTIVE: To measure the implementation of WHO Framework Convention on Tobacco Control (FCTC) Article 5.3 at country level using a new Tobacco Industry Interference Index and to report initial results using this index in seven Southeast Asian countries. METHODS: Score sheet based on WHO FCTC Article 5.3 Guidelines sent to correspondents in seven Southeast Asian countries, using a scoring system designed with the help of tobacco control experts and validated through focused group discussions. RESULTS: The seven countries ranked from the lowest level of interference to the highest are Brunei, Thailand, Lao PDR, Cambodia, Philippines, Malaysia and Indonesia. Countries that face high levels of unnecessary interaction with the tobacco industry also face high levels of tobacco industry influence in policy development. Most governments do not allow any tobacco industry representatives on their delegation to sessions of the Conference of the Parties or its subsidiary bodies nor accept their sponsorship for delegates, but most governments still accept or endorse offers of assistance from the tobacco industry in implementing tobacco control policies. Most governments also receive tobacco industry contributions (monetary or in kind) or endorse industry corporate social responsibility activities. Governments do not have a procedure for disclosing interactions with the tobacco industry, but Lao PDR, Philippines and Thailand have instituted measures to prevent or reduce industry interference. CONCLUSIONS: This Tobacco Industry Interference Index, based on the WHO FCTC Article 5.3 Guidelines, is a useful advocacy tool for identifying both progress and gaps in national efforts at implementing WHO FCTC Article 5.3.

Tobacco industry's ITGA fights FCTC implementation in the Uruguay negotiations.

OBJECTIVE: To illustrate how the tobacco industry' front group, the International Tobacco Growers Association (ITGA), mobilised tobacco farmers to influence the fourth session of the Conference of the Parties (COP4) negotiations and defeat the adoption of Framework Convention on Tobacco Control Articles 9 and 10 Guidelines and Articles 17 and 18 progress report. METHODS: A review of COP4 documents on Articles 9, 10, 17 and 18 was triangulated with relevant information from tobacco industry reports, websites of British American Tobacco, Philip Morris International and ITGA, presentations by tobacco industry executives and internal industry documents from the Legacy Tobacco Documents Library website. RESULTS: Philip Morris International and British American Tobacco rejected Articles 9 and 10 draft Guidelines claiming that banning ingredients in cigarettes will render burley leaf less commercially viable making tobacco growers in many countries suffer economic consequences. They claimed the terms 'attractiveness' and 'palatability' are not appropriate regulatory standards. The ITGA launched a global campaign to mobilise farmers to reject the draft Guidelines at COP4 in Uruguay. Tobacco producers, Brazil, Philippines, Tanzania, Zambia, Malawi and Zimbabwe, sent large delegations to COP4 and participated actively in the negotiation on the draft Guidelines. Partial Guidelines on Articles 9 and 10 on product regulation and disclosure were adopted. COP4's work on Article 17 provides guidance on viable alternatives, but the ITGA is opposed to this and continues fight crop substitution. CONCLUSION: Despite ITGA's international campaign to thwart the Guidelines on Articles 9 and 10 and a strong representation from tobacco-growing countries at COP4, the outcome after intense negotiations was the adoption of Partial Guidelines and work on Articles 17 and 18 to proceed.

The lightest market in the world: light and mild cigarettes in Japan.

This article reviews the history of the introduction and use of light and mild labeled cigarettes in Japan, the "lightest" market in the world. Systematic keyword and opportunistic Web site searches were conducted on tobacco industry internal documents relevant to Japan, supplemented with relevant material from the tobacco trade and sociological literatures. Certain "market quirks" of the Japanese society benefited the tobacco industry in promoting its light and mild cigarettes. Japan's is a trend-conscious society with a penchant for new fashion and products. The Japanese are innovative, with the propensity to transform concepts into something characteristically their own marked by a distinct cultural style, such as the concept of keihaku tansho ("light-thin-short-small"). With big-budget sophisticated advertising, tobacco companies developed a lucrative market for mild, light, and ultra-low-tar cigarettes. Smokers had a preference for charcoal filters, which they believed protected them. Tar numbers meant little to smokers. The transnational tobacco companies capitalized on consumer concerns about the health hazards of smoking to promote low-tar cigarettes as a safer alternative. This may be one factor that explains why smoking prevalence in Japan remains high. Light and mild cigarettes are popular in Japan because Japanese smokers believe low tar/nicotine cigarette with charcoal filters protect them and help mollify their health concerns about smoking.

Health treaty dilution: a case study of Japan's influence on the language of the WHO Framework Convention on Tobacco Control.

BACKGROUND: The Japanese government is an important shareholder in the Japanese tobacco industry. Negotiations to develop the WHO's historic Framework Convention on Tobacco Control (FCTC) were based on consensus, resulting in countries needing to agree to the lowest acceptable common denominator in clause development. OBJECTIVE: To illustrate Japan's role in negotiating key optional language in the FCTC text. METHODS: Summary reports, text proposals, conference papers, and speeches related to the six FCTC negotiation sessions were reviewed for repeated words, concepts and emerging themes. Key stakeholders were interviewed. Key words such as "sovereignty", "appropriate", "latitude", "individual", "flexibility", and "may" representing optional language were examined. RESULTS: The Japanese government's proposals for "appropriate" and optional measures are reflected in the final FCTC text that accommodates flexibility on interpretation and implementation on key tobacco controls. While Japan was not alone in proposing optional language, consensus accommodated their proposals. CONCLUSION: Japan's success in arguing for extensive optional language seriously weakened the FCTC. Accordingly, international tobacco control can be expected to be less successful in reducing the burden of disease caused by tobacco use.