The global impact of tobacco control policies on smokeless tobacco use: a systematic review.

BACKGROUND: Smokeless tobacco, used by more than 300 million people globally, results in substantial morbidity and mortality. For smokeless tobacco control, many countries have adopted policies beyond the WHO Framework Convention on Tobacco Control, which has been instrumental in reducing smoking prevalence. The impact of these policies (within and outside the Framework Convention on Tobacco Control) on smokeless tobacco use remains unclear. We aimed to systematically review policies that are relevant to smokeless tobacco and its context and investigate their impact on smokeless tobacco use. METHODS: In this systematic review, we searched 11 electronic databases and grey literature between Jan 1, 2005, and Sept 20, 2021, in English and key south Asian languages, to summarise smokeless tobacco policies and their impact. Inclusion criteria were all types of studies on smokeless tobacco users that mentioned any smokeless tobacco relevant policies since 2005, except systematic reviews. Policies issued by organisations or private institutions were excluded as well as studies on e-cigarettes and Electronic Nicotine Delivery System except where harm reduction or switching were evaluated as a tobacco cessation strategy. Two reviewers independently screened articles, and data were extracted after standardisation. Quality of studies was appraised using the Effective Public Health Practice Project's Quality Assessment Tool. Outcomes for impact assessment included smokeless tobacco prevalence, uptake, cessation, and health effects. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. This systematic review was registered in PROSPERO (CRD42020191946). FINDINGS: 14 317 records were identified, of which 252 eligible studies were included as describing smokeless tobacco policies. 57 countries had policies targeting smokeless tobacco, of which 17 had policies outside the Framework Convention on Tobacco Control for smokeless tobacco (eg, spitting bans). 18 studies evaluated the impact, which were of variable quality (six strong, seven moderate, and five weak) and reported mainly on prevalence of smokeless tobacco use. The body of work evaluating policy initiatives based on the Framework Convention on Tobacco Control found that these initiatives were associated with reductions in smokeless tobacco prevalence of between 4·4% and 30·3% for taxation and 22·2% and 70·9% for multifaceted policies. Two studies evaluating the non-Framework policy of sales bans reported significant reductions in smokeless tobacco sale (6·4%) and use (combined sex 17·6%); one study, however, reported an increased trend in smokeless tobacco use in the youth after a total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found a 13·3% increase in quit attempts in individuals exposed (47·5%) to Framework Convention on Tobacco Control policy: education, communication, training, and public awareness, compared with non-exposed (34·2%). INTERPRETATION: Many countries have implemented smokeless tobacco control policies, including those that extend beyond the Framework Convention on Tobacco Control. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in smokeless tobacco use. FUNDING: UK National Institute for Health Research.

Global impact of tobacco control policies on smokeless tobacco use: a systematic review protocol.

INTRODUCTION: Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated. METHODS AND ANALYSIS: A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used. ETHICS AND DISSEMINATION: Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC_IEC_06_2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42020191946.

Compliance of smokeless tobacco supply chain actors and products with tobacco control laws in Bangladesh, India and Pakistan: protocol for a multicentre sequential mixed-methods study.

INTRODUCTION: South Asia is home to more than 300 million smokeless tobacco (ST) users. Bangladesh, India and Pakistan as signatories to the Framework Convention for Tobacco Control (FCTC) have developed policies aimed at curbing the use of tobacco. The objective of this study is to assess the compliance of ST point-of-sale (POS) vendors and the supply chain with the articles of the FCTC and specifically with national tobacco control laws. We also aim to assess disparities in compliance with tobacco control laws between ST and smoked tobacco products. METHODS AND ANALYSIS: The study will be carried out at two sites each in Bangladesh, India and Pakistan. We will conduct a sequential mixed-methods study with five components: (1) mapping of ST POS, (2) analyses of ST samples packaging, (3) observation, (4) survey interviews of POS and (5) in-depth interviews with wholesale dealers/suppliers/manufacturers of ST. We aim to conduct at least 300 POS survey interviews and observations, and 6-10 in-depth interviews in each of the three countries. Data collection will be done by trained data collectors. The main statistical analysis will report the frequencies and proportions of shops that comply with the FCTC and local tobacco control policies, and provide a 95% CI of these estimates. The qualitative in-depth interview data will be analysed using the framework approach. The findings will be connected, each component informing the focus and/or design of the next component. ETHICS AND DISSEMINATION: Ethical approvals for the study have been received from the Health Sciences Research Governance Committee at the University of York, UK. In-country approvals were taken from the National Bioethics Committee in Pakistan, the Bangladesh Medical Research Council and the Indian Medical Research Council. Our results will be disseminated via scientific conferences, peer-reviewed research publications and press releases.

The tobacco industry's challenges to standardised packaging: A comparative analysis of issue framing in public relations campaigns in four countries.

Tobacco industry public relations campaigns have played a key role in challenges to standardised cigarette packaging. This paper presents a comparative analysis of industry campaigns in Australia and the United Kingdom, which have implemented standardised packaging legislation; Canada, where policy has been adopted but not yet implemented; and the Netherlands, which has considered, but not enacted regulation. Campaigns were identified via Google searches, tobacco industry websites, media coverage, government submissions and previous research; analysis focused on issue framing and supporting evidence. Public relations campaigns in all case study countries drew on similar frames - the illicit trade in tobacco products, the encroaching 'nanny state', lack of evidence for the effectiveness of standardised packaging, a slippery slope of regulation, and inherent threats to intellectual property rights. These claims were supported by industry research, front groups and commissioned reports by accountancy firms, but were not with verifiable research. Independent evidence that contradicted industry positions was overlooked. Similarities in structure and content of public relations campaigns in countries that have enacted or considered regulation points to a strategic co-ordinated approach by cigarette manufacturers. Countries considering standardised packaging policy can expect powerful opposition from the tobacco industry. Tobacco control communities and policy makers can learn from previous experience, and share best practise in countering industry arguments.

Introduction: Bringing Institutions Back in the Study of Global Value Chains.

The article introduces and summarizes the key questions and findings of this special issue of Global Policy on the role of domestic and international institutions in the study of Global Value Chains (GVCs). The article starts by briefly introducing the concept of GVCs and the state-of-the-art of the existing literature focusing on the political implications of these landmark changes in the global economy. Then we make a case for grounding this emerging literature more strongly into an "institutionalist" perspective. More specifically, we argue that while a great deal of attention has been paid to intra-chain governance modes - i.e. the different ways in which firms organize their cross-border production arrangements - the role external institutional forces play in structuring chain dynamics remains surprisingly under-researched. These observations invite an analytical perspective that brings institutions back into the study of GVCs. The contributions to the special issue focus on multiple causal pathways linking GVCs and various types of domestic- and international institutions. Altogether, these contributions underscore that the politics engendered by GVCs, as well as how they evolve, can only be fully understood by paying attention to the external institutional context in which they are embedded.

Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries.

Tobacco is widely considered to be a uniquely harmful product for human health. Since the mid-1990s, the strategies of transnational tobacco corporations to undermine effective tobacco control policy has been extensively documented through internal industry documents. Consequently, the sale, use and marketing of tobacco products are subject to extensive regulation and formal measures to exclude the industry from policy-making have been adopted in the Framework Convention on Tobacco Control. In contrast to tobacco, alcohol is subject to less stringent forms of regulation, and the alcohol industry continues to play a central role in policy-making in many countries and at the global level. This article examines whether there is a sufficient rationale for such different regulatory approaches, through a comparative analysis of the political economy of the tobacco and alcohol industries including the structure of the industries, and the market and political strategies they pursue. Despite some important differences, the extensive similarities which exist between the tobacco and alcohol industries in terms of market structure and strategy, and political strategy, call into question the rationale for both the relatively weak regulatory approach taken towards alcohol, and the continued participation of alcohol corporations in policy-making processes.

Smoke screen? The globalization of production, transnational lobbying and the international political economy of plain tobacco packaging.

In 2012 Australia became the first country in the world to introduce plain tobacco packaging in an effort to reduce tobacco consumption. This move was vehemently opposed by the tobacco industry, which challenged it on several levels: nationally, bilaterally and multilaterally at the World Trade Organization (WTO). The political behavior of the tobacco companies in this case is puzzling both in terms of scale, operating at multiple levels at the same time and in terms of the countries mobilized in their defence. WTO litigation is typically the result of Multi National Enterprises (MNEs) lobbying their own government, but here third countries were mobilized. Lobbying in third country contexts, with the objective of accessing multilateral dispute settlement systems, has been little studied. We thus know very little about the driving factors behind such activities, how target governments are selected and what lobbying strategies are used. This paper draws on emerging research on transnational lobbying and a case study of the PP case to explore these issues in detail and, by doing so, aims to further our theoretical understanding of the political economy of international trade in the context of increasing regime complexity and globalization of production.

The Taiwan Tobacco and Liquor Corporation: To 'join the ranks of global companies'.

Until the late 1990s, the Taiwan Tobacco and Liquor Corporation (TTL) focused almost exclusively on serving the domestic market as a highly protected monopoly. This paper describes how the company has adopted a more outward looking strategy since 2000, with ambitions to become a regional, and eventually global, business by 2021. Drawing on company documents and industry sources, the paper argues that this shift in strategy was a direct reaction to the decline in domestic market share following liberalisation of the Taiwanese tobacco market and adoption of tougher domestic tobacco control measures. Market opening occurred as a result of pressure from the U.S. Trade Representative in the 1980s, as well as World Trade Organization membership in 2002. It is argued that TTL's efforts to globalise operations have been limited by bureaucratic company management and structures, and ongoing political tension between Taiwan and China. However, the relative success of TTL's alcohol branch, and potential détente as the Taiwanese government reaches out to improve relations with China, may provide TTL with new opportunities to achieve its goal of becoming a regional player with global ambitions. This article is part of the special issue 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.'

KT&G: From Korean monopoly to 'a global name in the tobacco industry'.

Until the late 1980s, the former South Korean tobacco monopoly KT&G was focused on the protected domestic market. The opening of the market to foreign competition, under pressure from the U.S. Trade Representative, led to a steady erosion of market share over the next 10 years. Drawing on company documents and industry sources, this paper examines the adaptation of KT&G to the globalization of the South Korean tobacco industry since the 1990s. It is argued that KT&G has shifted from a domestic monopoly to an outward-looking, globally oriented business in response to the influx of transnational tobacco companies. Like other high-income countries, South Korea has also seen a decline in smoking prevalence as stronger tobacco control measures have been adopted. Faced with a shrinking domestic market, KT&G initially focused on exporting Korean-manufactured cigarettes. Since the mid-2000s, a broader global business strategy has been adopted including the building of overseas manufacturing facilities, establishing strategic partnerships and acquiring foreign companies. Trends in KT&G sales suggest an aspiring transnational tobacco company poised to become a major player in the global tobacco market. This article is part of the special issue 'The emergence of Asian tobacco companies: Implications for global health governance'.

Japan Tobacco International: To 'be the most successful and respected tobacco company in the world'.

Japan Tobacco International (JTI) is the international division of Japan Tobacco Incorporated, and the world's third largest transnational tobacco company. Founded in 1999, JTI's rapid growth has been the result of a global business strategy that potentially serves as a model for other Asian tobacco companies. This paper analyses Japan Tobacco Incorporated's global expansion since the 1980s in response to market opening, foreign competition, and declining share of a contracting domestic market. Key features of its global strategy include the on-going central role and investment by the Japanese government, and an expansion agenda based on mergers and acquisitions. The paper also discusses the challenges this global business strategy poses for global tobacco control and public health. This paper is part of the special issue 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance'.

The globalisation strategies of five Asian tobacco companies: a comparative analysis and implications for global health governance.

The global tobacco industry, from the 1960s to mid 1990s, saw consolidation and eventual domination by a small number of transnational tobacco companies (TTC). This paper draws together comparative analysis of five case studies in the special issue on 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance.' The cases suggest that tobacco industry globalisation is undergoing a new phase, beginning in the late 1990s, with the adoption of global business strategies by five Asian companies. The strategies were prompted foremost by external factors, notably market liberalisation, competition from TTCs and declining domestic markets. State protection and promotion enabled the industries in Japan, South Korea and China to rationalise their operations ahead of foreign market expansion. The TTM and TTL will likely remain domestic or perhaps regional companies, JTI and KT&G have achieved TTC status, and the CNTC is poised to dwarf all existing companies. This global expansion of Asian tobacco companies will increase competition which, in turn, will intensify marketing, exert downward price pressures along the global value chain, and encourage product innovation. Global tobacco control requires fuller understanding of these emerging changes and the regulatory challenges posed by ongoing globalisation.

The globalisation strategies of five Asian tobacco companies: An analytical framework.

With 30% of the world's smokers, two million deaths annually from tobacco use, and rising levels of tobacco consumption, the Asian region is recognised as central to the future of global tobacco control. There is less understanding, however, of how Asian tobacco companies with regional and global aspirations are contributing to the global burden of tobacco-related disease and death. This introductory article sets out the background and rationale for this special issue on 'The Emergence of Asian Tobacco Companies: Implications for Global Health Governance'. The article discusses the core questions to be addressed and presents an analytical framework for assessing the globalisation strategies of Asian tobacco firms. The article also discusses the selection of the five case studies, namely as independent companies in Asia which have demonstrated concerted ambitions to be a major player in the world market.

The Politics of Global Value Chains: Import-dependent Firms and EU-Asia Trade Agreements.

In 2006, the European Commission released its Global Europe Communication, in which it announced a shift from a multilateral to a bilateral trade strategy. One of the key pillars of this new strategy was to strengthen the bilateral trade relations with key Asian countries. In contrast to existing analyses that focus on European Union (EU) decision makers' agency, we propose an explanation for this notable shift in the EU's trade policy that stresses the political role of import-dependent firms. In light of the increasing integration of such firms into global value chains, the article argues that a plausible case can be made, both theoretically and empirically, that import-dependent firms had a clear stake in the signing of preferential trade agreements between the EU and Asian countries and that their lobbying efforts significantly affected the EU's decision to start negotiations with South Korea, India and Vietnam.

Tobacco control and the World Trade Organization: mapping member states' positions after the framework convention on tobacco control.

OBJECTIVE: To note the frequency of discussions and disputes about tobacco control measures at the World Trade Organization (WTO) before and after the coming into force of the Framework Convention on Tobacco Control (FCTC). To review trends or patterns in the positions taken by members of the WTO with respect to tobacco control measures. To discuss possible explanations for these observed trends/patterns. METHODS: We gathered data on tobacco-related disputes in the WTO since its establishment in 1995 and its forerunner, the General Agreement on Tariffs and Trade (GATT), prior-FCTC and post-FCTC. We also looked at debates on tobacco control measures within the WTO more broadly. To this end, we classified and coded the positions of WTO member states during discussions on tobacco control and the FCTC, from 1995 until 2013, within the Technical Barriers to Trade (TBT) Committee and the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Council. RESULTS: There is a growing interest within the WTO for tobacco-related issues and opposition to tobacco control measures is moving away from high-income countries towards low(er) income countries. CONCLUSIONS: The growing prominence of tobacco issues in the WTO can be attributed at least in part to the fact that during the past decade tobacco firms have been marginalised from the domestic policy-making process in many countries, which has forced them to look for other ways and forums to influence decision-making. Furthermore, the finding that almost all recent opposition within the WTO to stronger tobacco regulations came from developing countries is consistent with a relative shift of transnational tobacco companies' lobbying efforts from developed to developing countries.

Tobacco industry globalization and global health governance: towards an interdisciplinary research agenda.

Shifting patterns of tobacco production and consumption, and the resultant disease burden worldwide since the late twentieth century, prompted efforts to strengthen global health governance through adoption of the Framework Convention on Tobacco Control. While the treaty is rightfully considered an important achievement, to address a neglected public health issue through collective action, evidence suggests that tobacco industry globalization continues apace. In this article, we provide a systematic review of the public health literature and reveal definitional and measurement imprecision, ahistorical timeframes, transnational tobacco companies and the state as the primary units and levels of analysis, and a strong emphasis on agency as opposed to structural power. Drawing on the study of globalization in international political economy and business studies, we identify opportunities to expand analysis along each of these dimensions. We conclude that this expanded and interdisciplinary research agenda provides the potential for fuller understanding of the dual and dynamic relationship between the tobacco industry and globalization. Deeper analysis of how the industry has adapted to globalization over time, as well as how the industry has influenced the nature and trajectory of globalization, is essential for building effective global governance responses. This article is published as part of a thematic collection dedicated to global governance.

Support for international trade law: The US and the EU compared.

In this article we compare US and EU support for bilateral and multilateral international trade law. We assess the support for international law of both trading blocs by focusing on the following four dimensions: leadership, consent, compliance and internalization. Although we find strong support for international trade law from both the US and the EU in general, we also witness some variation, most notably in relation to the design of preferential trade agreements (PTAs) and compliance with World Trade Organization (WTO) law. Turning to explaining these (moderate) differences, we argue that outcomes in US trade policy can best be explained by a domestic political factor, namely the direct influence of interest groups. Although the involvement of societal interests also goes a long way in explaining EU behavior, it does not tell the entire story. We posit that, in EU trade policy, institutions are a particular conditioning factor that needs to be stressed. Moreover, we suggest that foreign policy considerations in managing trade relations have characterized EU's support for international trade law.