Inhibitors and Supporters of Policy Change in the Regulation of Unhealthy Food Marketing in Australia.

BACKGROUND: Evidence on the impact of policies that regulate unhealthy food marketing demonstrates a need for a shift from pure industry self-regulation toward statutory regulation. Institutional rules, decision-making procedures, actor practices and institutional norms influence the regulatory choices made by policymakers. This study examined institutional processes that sustain, support, or inhibit change in the food marketing regulation in Australia using the three pillars of institutions framework - regulatory, normative and cultural cognitive pillars. METHODS: This was a qualitative study. Twenty-four in-depth semi-structured interviews were conducted with industry, government, civil society, and academic actors who are involved in nutrition policy in Australia. RESULTS: The regulatory pillar was perceived to inhibit policy change through the co-regulation and self-regulation frameworks that assign rulemaking, monitoring and enforcement to industry bodies with minimal oversight by regulatory agencies and no involvement of health actors. The normative pillar was perceived to provide pathways for comprehensive statutory regulation through institutional goals and norms for collaboration that centre on a whole-of-government approach. The framing of food marketing policies to highlight the vulnerability of children is a cultural cognitive element that was perceived to be essential for getting support for policy change; however, there was a lack of shared understanding of food marketing as a policy issue. In addition, government ideologies that are perceived to be reluctant to regulate commercial actors and values that prioritize economic interest over public health make it difficult for health advocates to argue for statutory regulation of food marketing. CONCLUSION: Elements of all three pillars (regulatory, normative and cultural-cognitive) were identified as either inhibitors or pathways that support policy change. This study contributes to the understanding of factors that inhibit policy change and potential pathways for implementing comprehensive statutory regulation of unhealthy food marketing.

The WHO Foundation in global health governance: Depoliticizing corporate philanthropy.

The creation of the WHO Foundation during the COVID-19 pandemic represents a significant institutional development in the politics of financing the World Health Organization (WHO). In the context of longstanding acute financial pressures, the objective of the WHO Foundation is to widen WHO's resource base by attracting philanthropic donations from the commercial sector. In placing funding decisions 'at one remove' from WHO, the stated expectation is that the WHO Foundation will act as an intermediary, insulating the WHO from potential conflicts of interest and reputational risk through a combination of strategic distance from WHO and proximity with its norms and rules of engagement with non-state actors. Yet, whether this model has translated into practice remains understudied. In this article, we focus on emerging institutional practices within the WHO Foundation, highlighting a drift from its stated governance model. Based on analysis of WHO Foundation documents, we demonstrate how due diligence and transparency practices within the Foundation have been redesigned in ways that contradict or subvert its claims to applying alignment with WHO's governance norms, notably relating to its engagement with health harming industries such as alcohol and petrochemical companies. While this situation may seem paradoxical, we argue that, in placing funding decisions 'at one remove' from the formal institutions and structures of WHO, the creation of the Foundation has served to displace this issue to a more secluded arena where drifts in practice are less exposed to political oversight and scrutiny. Focusing on the discursive aspects of this process of depoliticisation, we contend that the Foundation has strategically managed 'fictional expectations' of accountable and transparent governance in order to mitigate concerns about its mandate and functions. This assessment provides new and important insights into the depoliticizing functions of the WHO Foundation and the significant implications this may have for global health governance.

Protecting children from unhealthy food marketing: a comparative policy analysis in Australia, Fiji and Thailand.

Restrictions on marketing of unhealthy foods and beverages to children is a globally recommended policy measure to improve diets and health. The aim of the analysis was to identify opportunities to enable policy learning and shift beliefs of relevant actors, to engender policy progress on restrictions on marketing of unhealthy foods to children. We drew on the Advocacy Coalition Framework to thematically analyse data from qualitative policy interviews conducted Australia (n = 24), Fiji (n = 10) and Thailand (n = 20). In all three countries two clear and opposing advocacy coalitions were evident within the policy subsystem related to regulation of unhealthy food marketing, which we termed the 'strengthen regulation' and 'minimal/self regulation' coalitions. Contributors to policy stasis on this issue were identified as tensions between public health and economic objectives of government, and limited formal and informal spaces for productive dialogue. The analysis also identified opportunities for policy learning that could enable policy progress on restrictions on marketing of unhealthy foods to children as: taking an incremental approach to policy change, defining permitted (rather than restricted) foods, investing in new public health expertise related to emerging marketing approaches and scaling up of monitoring of impacts. The insights from this study are likely to be relevant to many countries seeking to strengthen regulation of marketing to children, in response to recent global recommendations.

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.

Conceptualising the commercial determinants of suicide: broadening the lens on suicide and self-harm prevention.

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward.

Commercial determinants of health: future directions.

This paper is about the future role of the commercial sector in global health and health equity. The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health-the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort.

Framework Convention on Tobacco Control 2030-A Program to Accelerate the Implementation of World Health Organization Framework Convention for Tobacco Control in Low- and Middle-Income Countries: A Mixed-Methods Evaluation.

BACKGROUND: Framework Convention on Tobacco Control (FCTC) 2030 Program (2017-2021) was launched to accelerate World Health Organization (WHO) FCTC implementation in 15 low- and middle-income countries (LMICs). We evaluated the Program in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion, and Sponsorship (TAPS) bans; and International and Regional Cooperation. AIMS AND METHODS: Following a mixed-methods design, we surveyed (June-September 2020) FCTC focal persons in 14 of the 15 countries, to understand the Program's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial = 1, technical = 1, or both = 2) and progress (none = 1, some = 2, partial = 3, or strong = 4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings. RESULTS: FCTC 2030 offered substantial financial and technical inputs, responsive to country needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r = 0.61 for taxation (p < .05) to r = 0.91 and for smoke-free policies (p < .001). The interviews indicated that the Program provided timely and relevant evidence and created opportunities for influencing tobacco control debates. CONCLUSIONS: The FCTC 2030 Program might have led to variable, but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation. IMPLICATIONS: What this study adds: In many LMICs, WHO FCTC policies are not in place; and even when enshrined in law, they are poorly enforced. It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies are likely to lead to progress in tobacco control.

Towards reconciling population nutrition goals and investment policy in Thailand: understanding how investment policy actors defined, framed and prioritised nutrition.

BACKGROUND: Government's investment policy is an important driver of food system activities, which in turn influence consumers practices, dietary consumption patterns and nutrition-related health of populations. While governments globally have committed to developing coherent public policies to advance population nutrition, the objectives of investment policies are seen as being divorced from nutrition and health goals. This study aimed to examine investment policy in Thailand and explore how key actors variously define and frame their objectives in food investment policy, how nutrition issues are represented by the actors, and what discursive effects of the nutrition results were represented within the field of investment in Thailand. METHODS: This study conducted semi-structured interviews with 16 actors (from 23 recruited actors) from government, civil society, academia and industry. A coding framework was developed based on Bacchi's analytical framework encapsulated in the question "What's the problem represented to be?" which examines the problem and assumptions underlying a policy. Data coding was first undertaken by a lead researcher and then double-coded and cross-checked by research team. Disagreements were resolved with discussion until consensus was achieved. The interview data were analysed using thematic analysis. RESULTS: The principal "problem" represented in food investment policy in Thailand was the perceived irrelevance of nutrition to governmental commitments towards increasing productivity and economic growth. Technological innovation in food production and processing such as ultra-processed foods was perceived as a key driver of economic growth. The key assumption underlying this representation was the primacy of a "productivist" policy paradigm, via which the government focuses on industrially driven food and agriculture and expansion to increase productivity and economic growth. This entails that the nutrition needs of Thai people are silenced and remain unacknowledged in investment policy contexts, and also does not take cognisance of the term "nutrition" and its importance to economic growth. CONCLUSION: The findings show that nutrition was not perceived as a political priority for the government and other investment actors. Promoting productivity and economic growth were clearly positioned as the primary purposes of investment within the dominant discourse. Nutrition regulation, particularly of UPF, may conflict with current investment policy directions which prioritise development of modern food production and processing. The study suggests that comprehensive policy communication about nutrition and food classification is needed.

How commercial actors used different types of power to influence policy on restricting food marketing: a qualitative study with policy actors in Thailand.

OBJECTIVES: There is limited research focused explicitly on understanding how commercial actors use different forms of power to influence policy decision making in Thailand. This study aimed to identify how the food industry has used structural, instrumental and discursive power to influence policy on restricting food marketing in Thailand. STUDY DESIGN: Qualitative study using in-depth semistructured interviews SETTINGS: Thailand. PARTICIPANTS: The interviews were conducted with 20 participants (of a total of 29 invited actors) from government, civil society, technical experts, international organisation and the food and advertising industry. Interview data were identified in the transcripts and analysed using abductive methods. RESULTS: Non-commercial actors perceived the commercial actors' structural power (its economic influence and structurally privileged position) as central to understanding the government having not implemented policy to restrict food marketing. The commercial actors' instrumental power was observed through sponsorship, campaign and lobbying activities. Discursive power was used by the industry to shift responsibility away from the food companies and onto their customers, by focusing their messaging on freedom of consumer choice and consumer health literacy. CONCLUSIONS: This study examined different types of power that commercial actors were perceived to use to influence policy to restrict food marketing in Thailand. The study showed arguments and institutional processes used to enhance commercial actors' ability to shape the policy decision for nutrition, public opinion and the broader regulatory environment. The findings help governments and other stakeholders to anticipate industry efforts to counter policy. The findings also suggest the need for governance structures that counter industry power, including comprehensive monitoring and enforcement in policy implementation.

Authority in tobacco control in Pacific Small Island Developing States: a qualitative study of multisectoral tobacco governance in Fiji and Vanuatu.

OBJECTIVE: Small Island Developing States (SIDS) struggle with implementing multisectoral tobacco control measures, and health sector actors often lack capacity to forge multisectoral commitment. This study aims to explore the sources and dynamics of authority that can enable multisectoral collaboration despite the divergence of policy agendas in tobacco control. METHODS: We applied a qualitative, explorative case study design, with data collection and analysis guided by an analytical framework that identifies sources and dynamics of authority. Seventy interviews were conducted in Fiji and Vanuatu between 2018 and 2019. RESULTS: The key features shaping multisectoral coordination for tobacco control in Fiji and Vanuatu are the expert, institutional, capacity-based and legal authority that state and non-state actors have in tobacco governance. The amount of authority actors can secure from these sources was shown to be influenced by their performance (perceived or real), the discourse around tobacco control, the existing legal tools and their strategic alliances. SIDS vulnerabilities, arising from small size, isolation and developing economies, facilitate an economic growth discourse that reduces health sector actors' authority and empowers protobacco actors to drive tobacco governance. CONCLUSIONS: Our results highlight the need for terms of engagement with the tobacco industry to enable governments to implement multisectoral tobacco control measures. Expanding assistance on tobacco control among government and civil society actors and increasing messaging about the impact of economic, trade and agricultural practices on health are essential to help SIDS implement the Framework Convention on Tobacco Control.

Governing ultra-processed food and alcohol industries: the presence and role of non-government organisations in Australia.

OBJECTIVE: The roles of non-governmental organisations (NGOs) in regulating harmful commodity industries (HCIs) are understudied. The aim of this paper is to identify the NGOs and the roles that they play in the governance of the ultra-processed food and alcohol industries in Australia. METHODS: We undertook an exploratory descriptive analysis of NGOs identified from an online search based on the typology we developed of type, issue area and governance function. RESULTS: A total of 134 relevant Australian NGOs were identified: 38 work on food issues, 61 with alcohol issues and 35 are active in both. In the food domain, 90% of NGOs engage in agenda setting, 88% in capacity building, 15% in implementation and 12% in monitoring. In the alcohol domain, 92% of NGOs are active in agenda setting, 72% in capacity building, 35% in implementation and 8% in monitoring. CONCLUSIONS: Australian NGOs are active actors in the food and alcohol governance system. IMPLICATIONS FOR PUBLIC HEALTH: There are many opportunities for NGOs to regulate HCI practices, building on their relative strengths in agenda setting and capacity building, and expanding their activities in monitoring and implementation. A more detailed examination is needed of strategies that can be used by NGOs to be effective regulators in the governance system.

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.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health.

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

Moving from silos to synergies: strengthening governance of food marketing policy in Thailand.

BACKGROUND: Governance processes play an important role in shaping the formulation and implementation of policy measures such as restrictions on marketing of ultra-processed foods. However, there is limited analysis of the factors that affect governance for nutrition, especially in low- and middle-income countries such as Thailand and the Southeast Asia region. This study aimed to examine governance factors that create opportunities and challenges for the introduction of policy to restrict food marketing in Thailand, in line with the WHO recommendations to restrict food marketing to children. METHODS: A qualitative study design was used. Interviews were conducted with 20 actors with experience and in depth knowledge of food marketing in Thailand, including government, civil society, industry and international organisations. Open questions were asked about experiences and perceptions of the governance processes related to policies for restricting food marketing in Thailand. Themes were derived from the 3-i Framework which relates to interests, ideas and institutions influencing the introduction of food marketing policy were identified and analysed using abductive methods. RESULTS: Actors viewed institutional challenges as a significant barrier to advancing effective regulation of food marketing. Three major clusters emerged from the data: interests (priorities, relationships), institutions (formal structures, informal structures, broader institutional strategies), and ideas (norms). The study has three major findings in relation to these factors, highlighting the influence of formal structures, institutional interests in food marketing issues, and ideas in promoting multisectoralism. The siloed nature of policymaking was reflected in the government failing to stimulate engagement among key actors, posing challenges for implementation of effective policy change. Contested interests led to disagreements between actors over food marketing agenda and thus competing policy priorities. Consistent with these findings, the lack of effective mechanisms to promote multisectoral coordination across diverse actors reinforced barriers to policy change. CONCLUSION: The findings highlight ongoing challenges to the government's aim to strengthen policy to restrict food marketing which, without greater coordination in governance mechanisms, will hinder effective regulation and the achievement of public health goals. This analysis suggests that the Government should prioritise the development of a holistic, multisectoral approach to improve governance for better nutrition outcomes by overcoming policy silos.

'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.

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.

Challenges of conflict of interest, coordination and collaboration in small island contexts: towards effective tobacco control governance in UK Overseas Territories.

INTRODUCTION: The UK Overseas Territories (UKOTs) are semi-autonomous jurisdictions that face distinctive challenges in implementing tobacco control and protecting policy from industry influence. They are not eligible to become independent parties of the WHO Framework Convention on Tobacco Control (FCTC), although they can apply for treaty extension under the UK's ratification. This study explores the relevance of the FCTC-particularly Article 5.3-for tobacco control governance across a sample of UKOTs. METHODS: From March to May 2019, we interviewed 32 stakeholders across four territories (Anguilla, Bermuda, Cayman Islands, St Helena) at diverse stages in implementing key FCTC measures. Thematic qualitative analysis explored awareness and perceptions in relation to tobacco control. RESULTS: Interviewees' accounts highlight the complexity of protecting health policy from industry influence in a context where the 'tobacco industry' covers a diverse range of actors. Despite not being formally covered by the FCTC, several health officials spoke about the strategic value of invoking Article 5.3 in the context of tensions with economic priorities. Nevertheless, effective tobacco control governance is complicated by territories' reliance on local businesses-including tourism-and close social connections that occasionally blur the lines between private and public spheres. CONCLUSIONS: The UKOTs share many characteristics with other small island jurisdictions, creating distinctive challenges for advancing tobacco control and protecting policy from industry interference. Despite their complex status in relation to WHO and its architecture, these territories benefit from the norms embedded in the FCTC and the systems that support its implementation.