Addressing tobacco industry influence in tobacco-growing countries.

Protecting policy-making from tobacco industry influence is central to effective tobacco control governance. The inclusion of industry actors as stakeholders in policy processes remains a crucial avenue to corporate influence. This influence is reinforced by the idea that the tobacco industry is a legitimate partner to government in regulatory governance. Addressing the influence of the tobacco industry demands a focus on the government institutions that formalize relationships between industry and policy-makers. Industry involvement in government institutions is particularly relevant in tobacco-growing countries, where sectors of government actively support tobacco as an economic commodity. In this paper, we discuss how controlling tobacco industry influence requires unique consideration in tobacco-growing countries. In these countries, there is a diverse array of companies that support tobacco production, including suppliers of seeds, equipment and chemicals, as well as transportation, leaf buying and processing, and manufacturing companies. The range of companies that operate in these contexts is particular and so is their engagement within political institutions. For governments wanting to support alternatives to tobacco growing (Article 17 of the Framework Convention for Tobacco Control), we illustrate how implementing Article 5.3, aimed at protecting tobacco control policies from tobacco industry interference, is fundamental in these countries. Integrating Article 5.3 with Article 17 will (i) strengthen policy coherence, ensuring that alternative livelihood policies are not undermined by tobacco industry interference; (ii) foster cross-sector collaboration addressing both tobacco industry interference and livelihood development; and (iii) enhance accountability and transparency in tobacco control efforts.

Éviter que l'élaboration de politiques soit influencée par l'industrie du tabac est essentiel pour assurer une gestion efficace de la lutte antitabac. L'inclusion d'acteurs de l'industrie comme parties prenantes des processus législatifs demeure l'un des principaux leviers employés par les sociétés. Cette influence est renforcée par l'idée que l'industrie du tabac constitue un partenaire légitime du gouvernement dans le domaine de la gouvernance réglementaire. Pour lutter contre l'ingérence du secteur, il faut se concentrer sur les institutions gouvernementales qui officialisent les relations entre l'industrie et les responsables politiques. L'implication de l'industrie dans les institutions publiques est surtout observée dans les pays producteurs de tabac, où certains niveaux de gouvernement soutiennent activement le tabac en tant que bien économique. Dans le présent document, nous abordons le fait qu'une lutte contre l'influence de l'industrie du tabac requiert une attention particulière dans les pays producteurs, où un large éventail d'entreprises encouragent la production de tabac: approvisionnement en semences, équipements et produits chimiques, mais aussi transport, achat des feuilles, transformation et fabrication. La variété des entreprises œuvrant dans de tels contextes est spécifique, tout comme leur engagement au sein des organes politiques. Pour les gouvernements qui souhaitent privilégier les alternatives à la production de tabac (selon l'article 17 de la Convention-cadre pour la lutte antitabac), nous montrons à quel point l'application de l'article 5.3, qui vise à protéger les politiques de lutte antitabac contre l'ingérence de l'industrie, est fondamentale dans ces pays. Intégrer l'article 5.3 dans l'article 17 permettra (i) de renforcer la cohérence des politiques en vigueur, afin que les politiques relatives à des activités de remplacement ne soient pas contrecarrées par l'industrie du tabac; (ii) de favoriser la collaboration entre les secteurs pour lutter contre l'influence de l'industrie tout en développant des moyens de subsistance; et enfin, (iii) d'accroître la responsabilisation et la transparence dans les efforts menés dans la lutte antitabac.

Proteger la formulación de políticas contra la influencia de la industria tabacalera es fundamental para una gobernanza eficaz del control del tabaco. La inclusión de los actores de la industria como partes interesadas en los procesos políticos sigue siendo una vía crucial para la influencia corporativa. Esta influencia se ve reforzada por la idea de que la industria tabacalera es un asociado legítimo del gobierno en la gobernanza reglamentaria. La lucha contra la influencia de la industria tabacalera exige centrarse en las instituciones gubernamentales que formalizan las relaciones entre la industria y los responsables de formular políticas. La participación de la industria en las instituciones gubernamentales es especialmente relevante en los países productores de tabaco, donde algunos sectores del gobierno apoyan activamente el tabaco como un bien económico. En este documento, se analiza cómo el control de la influencia de la industria tabacalera requiere una consideración especial en los países productores de tabaco. En estos países, existe una gran variedad de empresas que apoyan la producción de tabaco, incluidos los proveedores de semillas, equipos y productos químicos, así como las empresas de transporte, de compra de hojas y de procesamiento y fabricación. La variedad de empresas que operan en estos contextos es particular y también lo es su compromiso dentro de las instituciones políticas. Para los gobiernos que desean apoyar alternativas al cultivo de tabaco (es decir, el artículo 17 del Convenio Marco para el Control del Tabaco), se ilustra cómo la aplicación del artículo 5.3, destinado a proteger las políticas de control del tabaco de la interferencia del tabaco, es fundamental en estos países. La integración del artículo 5.3 con el artículo 17 (i) reforzará la coherencia política, asegurando que las políticas de medios de vida alternativos no se vean perjudicadas por la interferencia de la industria tabacalera; (ii) fomentará la colaboración intersectorial al abordar tanto la interferencia de la industria tabacalera como el desarrollo de los medios de vida; y (iii) mejorará la rendición de cuentas y la transparencia en los esfuerzos de control del tabaco.

A framework of NGO inside and outside strategies in the commercial determinants of health: findings from a narrative review.

BACKGROUND: Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health. METHODS: We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice. RESULTS: One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative. CONCLUSION: The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.

Norms, rules and policy tools: understanding Article 5.3 as an instrument of tobacco control governance.

INTRODUCTION: Article 5.3 of the WHO Framework Convention on Tobacco Control, elaborated via its implementation guidelines, can be understood as a policy instrument comprising norms, rules and policy tools designed to shape practices of policy making and minimise tobacco industry interference. METHODS: This qualitative research is based on in-depth interviews with officials from diverse government sectors and non-governmental organisations across countries (Ethiopia, India, Uganda) that have adopted measures to implement Article 5.3. RESULTS: The data highlight varied perceptions and knowledge of Article 5.3 norms between health and non-health sectors. Health officials typically link its core norm of a fundamental conflict between public health and industry interests to the governance norm of protecting public health policies from industry interference. While officials in sectors beyond health broadly endorsed this core norm, they exhibited more limited awareness of Article 5.3 and its model of governance. The results examine how rules to implement Article 5.3 have been codified, but identify the absence of policy tools necessary to operationalise rules and norms. This limitation, alongside restricted awareness beyond health departments, suggests that political commitments to implement Article 5.3 will have limited impact on practices of stakeholder consultation and policy engagement with the tobacco industry. CONCLUSION: Conceptualising Article 5.3 as a policy instrument helps to explain how its rules and policy tools interact with each other and with broader governance processes. This framework has the potential to enhance understanding of Article 5.3 and help identify opportunities and constraints in its implementation.

Understanding the dynamics of notification and implementation of Article 5.3 across India's states and union territories.

INTRODUCTION: In federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India's federal system, examining how its guidelines have been operationalised across states and union territories. METHODS: Interviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019. RESULTS: The data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of 'socially responsible' industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees. CONCLUSION: The spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India's tobacco control legislation.

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.

'They have a right to participate as a stakeholder': Article 5.3 implementation and government interactions with the tobacco industry in Ethiopia.

INTRODUCTION: This paper explores implementation of Article 5.3 of the WHO Framework Convention on Tobacco Control in Ethiopia. The analysis highlights how operationalising key requirements of Article 5.3, such as minimising policy engagement with the tobacco industry, has been mediated by path-dependent processes of stakeholder consultation and collaboration that have persisted following privatisation of Ethiopia's state-owned tobacco monopoly. METHODS: We conducted semistructured interviews with key officials (n=21) working in tobacco control policy, with high levels of access secured across ministries and agencies beyond health. RESULTS: We found contrasting levels of awareness of Article 5.3 across government sectors, with extremely limited awareness in departments beyond health. The data also highlight competing ideas about conflict of interest, in which recognition of a fundamental conflict of interest with the tobacco industry is largely confined to health actors. Beyond limited cross-sectoral awareness and understanding of Article 5.3, gaps in implementation are exacerbated by assumptions and practices around stakeholder consultation, in which attempts to minimise policy interactions with the tobacco industry are mediated by institutionally embedded processes that presume active engagement. The results also highlight a continuation of the close relationship between the Ethiopian government and tobacco monopoly following its privatisation. CONCLUSION: The Ethiopian government's recent achievements in tobacco control legislation require that policymakers are actively supported in reconciling perceived tensions and requirements for stakeholder consultation. Effective tobacco control governance would be further enhanced by enabling government agencies to more clearly identify which interactions with the tobacco industry are strictly necessary under Article 5.3 guideline recommendations.

Institutional tensions, corporate social responsibility and district-level governance of tobacco industry interference: analysing challenges in local implementation of Article 5.3 measures in Karnataka, India.

INTRODUCTION: Accelerating progress on tobacco control will require Article 5.3 of the WHO Framework Convention on Tobacco Control to be systematically integrated into policies and practices of sectors beyond health at diverse government levels. However, no study has explored implementation challenges of Article 5.3 within multilevel systems such as India, where political decisions on tobacco control occur at diverse government levels, which may constrain action at local level. METHODS: Based on 33 semi-structured interviews with diverse government and civil society stakeholders across four districts in Karnataka, India (Mysore, Mangalore, Bengaluru (rural) and Udupi), this study examines challenges to implement Article 5.3 arising from competing agendas and policies of different actors at multiple levels. RESULTS: Our analysis reveals generally low levels of awareness of Article 5.3 and its guideline recommendations, even among those directly involved in tobacco control at district level. Efforts to implement Article 5.3 were also challenged by competing views on the appropriate terms of engagement with industry actors. Scope to reconcile tensions across competing health, agriculture and commercial agendas was further constrained by the policies and practices of the national Tobacco Board, thereby undermining local implementation of Article 5.3. The most challenging aspect of Article 5.3 implementation was the difficulties in restricting engagement by government officials and departments with tobacco industry corporate social responsibility initiatives given national requirements for such activities among major corporations. CONCLUSIONS: Promoting effective implementation of Article 5.3 in Karnataka will require policymakers to work across policy silos and reconcile tensions across India's national health and economic priorities.

'That is a Ministry of Health thing': Article 5.3 implementation in Uganda and the challenge of whole-of-government accountability.

INTRODUCTION: While Uganda has made legislative progress towards implementing Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC), ongoing challenges in minimising tobacco industry interference have not been adequately explored. This analysis focuses on understanding difficulties in managing industry engagement across government ministries and in developing effective whole-of-government accountability for tobacco control. METHODS: Interviews with Uganda government officials within the health sector and beyond, including in Ministries of Trade, Agriculture and Revenue. RESULTS: The findings indicate substantial variations in awareness of Article 5.3, its norm and practices across government sectors. The data suggest ambiguity and uncertainty about accountability for Article 5.3 implementation, with policy makers in departments beyond health often uncertain about obligations under the FCTC. Second, we highlight how responsibility for Article 5.3 implementation and the obligations incurred are widely seen as restricted to the Ministry of Health. Third, competing mandates and perceived difficulties in reconciling health goals with economic growth are shown to impact on accountability for tobacco control. Yet, importantly, the data also demonstrate enthusiasm in some unexpected parts of government for actively engaging with Article 5.3 and for promoting greater intersectoral coordination. CONCLUSION: This paper demonstrates the intrinsic challenges of developing whole-of-government approaches, highlighting considerable uncertainty and ambiguity among decision makers in Uganda about tobacco control governance. The analysis points to the potential for Uganda's national coordinating mechanism to help reconcile competing expectations and demonstrate the importance of Article 5.3 beyond health actors.

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

INTRODUCTION: Bangladesh has not yet adopted measures to implement Article 5.3 of the WHO Framework Convention on Tobacco Control. The National Tobacco Control Cell (NTCC) has drafted a guideline for implementation, but progress has stalled amid high levels of tobacco industry interference in public policy. This paper examines the barriers to minimising industry interference in a context of close relationships between government officials and tobacco companies. METHODS: In-depth interviews were conducted with government officials, representatives from civil society, think tank and media organisations, and academic researchers. The data were analysed using a '3 Is' framework developed within the political sciences, emphasising the interactive role of ideas, interests and institutions in policy change. RESULTS: The findings indicate that policy ideas about protecting public health policy making from tobacco industry interests are largely restricted to the Ministry of Health and Family Welfare, and the NTCC specifically. Both individual and institutional conflicts of interest emerge as key barriers to progress to minimising industry interference and for tobacco control governance more broadly. The data also suggest that development of an Article 5.3 guideline has been shaped by the perceived interests of political actors and institutions, and the institutional position of the NTCC, constrained by limits on its resources, authority and isolation from other ministries. CONCLUSION: NTCC's initiatives towards implementing Article 5.3 constitute an important opportunity to address conflicts of interest that restrict tobacco control in Bangladesh. Progress in minimising industry interference is essential to realising the commitment to being smoke free by 2040.

Non-communicable disease governance in the era of the sustainable development goals: a qualitative analysis of food industry framing in WHO consultations.

BACKGROUND: The UN system's shift towards multistakeholder governance, now embedded in the Sustainable Development Goals (SDGs), invites a broad range of actors, including the private sector, to the policymaking table. Although the tobacco industry is formally excluded from engagement, this approach provides opportunities for other unhealthy commodity industries to influence the World Health Organization's (WHO's) non-communicable disease (NCD) agenda. Focusing on the food industry, this research maps which actors engaged with WHO consultations, and critically examines actors' policy and governance preferences as well as the framing they employ to promote these preferences in the global context. METHODS: All written responses from food industry actors to publicly available NCD-relevant WHO consultations held between September 2015 and September 2018 were identified, totalling forty-five responses across five consultations. A qualitative frame analysis was conducted to identify policy positions expressed by respondents, as well as arguments and frames used to do so. RESULTS: Though no individual companies responded to the consultations, the majority of participating business associations had some of the largest multinational food corporations as members. Respondents overarchingly promoted non-statutory approaches and opposed statutory regulation and conflict of interest safeguards. To this purpose, they framed the food industry as a legitimate and necessary partner in policymaking, differentiating themselves from the tobacco industry and referencing a history of successful collaboration, while also invoking multistakeholder norms and good governance principles to portray collaboration as required. Respondents contrasted this with the limits of WHO's mandate, portraying it as out of step with the SDGs and framing NCD decision-making as a matter of national sovereignty. CONCLUSION: We observed that the UN's call for partnerships to support the SDGs is invoked to defend corporate access to NCD policy. This highlights the need for more cautious approaches which are mindful of the commercial determinants of health. Systematic opposition to regulation and to governance approaches which may compromise commercial actors' insider role in global health by food industry actors shown here, and the strategic use of the Sustainable Development agenda to this purpose, raises questions about the value of collaboration from the perspective of international health agencies such as WHO.

Can public health reconcile profits and pandemics? An analysis of attitudes to commercial sector engagement in health policy and research.

BACKGROUND: Public health's terms of engagement with unhealthy commodity industries (alcohol, tobacco and ultra-processed food and drinks) have become increasingly contested in policy and research. We sought to identify approaches that could attract consensus support within and across policy domains. METHODS: Using snowball sampling, we undertook an online survey of 335 health researchers, advocates and policymakers, in 40 countries, assessing responses to stated principles, claims and recommendations for engaging with unhealthy commodity industries in relation to key policy and research initiatives. RESULTS: Most respondents identified a fundamental conflict between industry interests and public health objectives for all three industries, with agreement greatest in relation to tobacco and weakest for food. This pattern was replicated across diverse questions regarding potential forms of engagement, including in rejecting voluntarism and partnership approaches to health policy. While awareness of tobacco industry tactics to influence policy and research was higher than for alcohol and food, most respondents rejected the view that the influence of the latter was less significant for public health. Proposals that health and research organisations should divest their funds attracted less support with respect to food, while restricting publication of industry-funded research in academic journals was the issue that most divided opinion. Respondents reported most difficulty in answering questions about the food industry. CONCLUSIONS: The strong consensus around restricting interactions with the tobacco industry supports increased implementation of the WHO Framework Convention on Tobacco Control's conflict of interest provisions. There is strong support for the extension of such practices to the alcohol industry, challenging current norms. More mixed responses indicate a need for greater clarity in defining the food industry, and for research analyzing links, similarities and differences across different types of unhealthy commodity producers. Partnership approaches to addressing non-communicable diseases seem incapable of attracting widespread support across public health, challenging practice in many contexts.