'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.

Health workers' perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda.

BACKGROUND: Tobacco use is associated with exacerbation of tuberculosis (TB) and poor TB treatment outcomes. Integrating tobacco use cessation within TB treatment could improve healing among TB patients. The aim was to explore perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda. METHODS: Between March and April 2019, nine focus group discussions (FGDs) and eight key informant interviews were conducted among health workers attending to patients with tuberculosis on a routine basis in nine facilities from the central, eastern, northern and western parts of Uganda. These facilities were high volume health centres, general hospitals and referral hospitals. The FGD sessions and interviews were tape recorded, transcribed verbatim and analysed using content analysis and the Chronic Care Model as a framework. RESULTS: Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. There was need to coordinate with different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities. CONCLUSIONS: Tobacco cessation activities should be provided in a continuum starting in the community before the TB patients get to hospital, during the patients' interface with hospital treatment and be given in the community after TB patients have been discharged. This requires collaboration between those who carry out health education in communities, the TB treatment supporters and the health workers who treat patients in health facilities.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda.

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either 'reputation' or 'respectability'. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

Tobacco control in the context of the COVID-19 pandemic in Uganda: a policy implementation review.

BACKGROUND: The COVID-19 pandemic has caused more than 900,000 deaths globally. The risk of mortality is higher for people with pre-existing conditions such as cancers, respiratory and cardiovascular diseases and diabetes for which tobacco use is a known risk factor. We conducted a study to explore how efforts to address the COVID-19 pandemic in Uganda have been integrated with tobacco control policies to generate evidence to inform policy decisions about the public health response in general and tobacco control interventions in particular. METHODS: We conducted a desk based review of 'grey' literature data sources (i.e. data that were not included in peer reviewed journals) with information about tobacco and COVID-19 in Uganda. Data were also obtained from stakeholders involved tobacco control via an online survey and telephone interviews. FINDINGS: A total of 136 data sources were identified, of which 107 were eligible for data extraction. The online stakeholder consultation involved invitations to 61 participants of whom 33 (54%) took part via the online survey while 5 (8.2%) opted for telephone interviews. In the context of the COVID-19 prevention interventions, social media can be a powerful platform for communicating anti-tobacco messages such as the vulnerability of tobacco users to COVID-19 and the exacerbated disease severity among COVID-19 patients with history of tobacco use. Two thirds (n=20, 65%) of survey respondents expected a tobacco tax increase to address health, economic and wider policy impacts of the COVID-19 crisis. CONCLUSIONS: Advocacy should be conducted for taxation of tobacco products to reduce consumption and generate revenue to support public health investments. Public health institutions involved in the COVID-19 response should reject donations from the tobacco industry and its allies as is stipulated in the Framework Convention on Tobacco Control and the Uganda Tobacco Control Act 2015. The COVID-19 pandemic also offers an opportunity to promote tobacco cessation and strengthening tobacco control policy implementation by recognizing the role of tobacco use in exacerbating COVID-19 health outcomes.

Implementation of 100% smoke-free law in Uganda: a qualitative study exploring civil society's perspective.

BACKGROUND: In 2016, Uganda became one of few sub-Saharan African countries to implement comprehensive national smoke-free legislation. Since the World Health Organisation recommends Civil Society Organisation's (CSO) involvement to support compliance with smoke-free laws, we explored CSOs' perceptions of law implementation in Kampala, Uganda, and the challenges and opportunities for achieving compliance. Since hospitality workers tend to have the greatest level of exposure to second-hand smoke, we focussed on implementation in respect to hospitality venues (bars/pubs and restaurants). METHODS: In August 2016, three months after law implementation, we invited key Kampala-based CSOs to participate in face-to-face semi-structured interviews. Interviews probed participants' perceptions about law implementation, barriers impeding compliance, opportunities to enhance compliance, and the role of CSOs in supporting law implementation. Interviews were recorded and transcribed. Qualitative content analysis was conducted using the interview transcripts. RESULTS: Fourteen individuals, comprising mainly senior managers from CSOs, participated and reported poor compliance with the smoke-free law in hospitality venues. Respondents noted that contributing factors included low awareness of the law amongst the general public and hospitality staff, limited implementation activities due to scarce resources and lack of coordinated enforcement. Opportunities for improving compliance included capacity building for enforcement agency staff, routine monitoring, rigorous enactment of penalties, and education about the smoke-free law aimed at hospitality venue staff and the general public. Allegations of tobacco industry misinformation were said to have undermined compliance. Civil Society Organisations saw their role as supporting law implementation through education, stakeholder engagement, and evidence-based advocacy. CONCLUSIONS: This study suggests that the process of smoke-free law implementation in Uganda has not aligned with World Health Organisation (WHO) guidelines for implementing smoke-free laws, and highlights that low-income countries may need additional support to enable them to effectively plan for policy implementation and resist industry interference.

Knowledge, opinions and compliance related to the 100% smoke-free law in hospitality venues in Kampala, Uganda: cross-sectional results from the KOMPLY Project.

OBJECTIVE: This study evaluated knowledge, opinions and compliance related to Uganda's comprehensive smoke-free law among hospitality venues in Kampala Uganda. DESIGN: This multi-method study presents cross-sectional findings of the extent of compliance in the early phase of Uganda's comprehensive smoke-free law (2 months postimplementation; pre-enforcement). SETTING: Bars, pubs and restaurants in Kampala Uganda. PROCEDURE AND PARTICIPANTS: A two-stage stratified cluster sampling procedure was used to select hospitality sites stratified by all five divisions in Kampala. A total of 222 establishments were selected for the study. One hospitality representative from each of the visited sites agreed to take part in a face-to-face administered questionnaire. A subsample of hospitality venues were randomly selected for tobacco air quality testing (n=108). Data were collected between June and August 2016. OUTCOME MEASURES: Knowledge and opinions of the smoke-free law among hospitality venue staff and owners. The level of compliance with the smoke-free law in hospitality venues through: (1) systematic objective observations (eg, active smoking, the presence of designated smoking areas, 'no smoking' signage) and (2) air quality by measuring the levels of tobacco particulate matter (PM2.5) in both indoor and outdoor venues. RESULTS: Active smoking was observed in 18% of venues, 31% had visible 'no smoking' signage and 47% had visible cigarette remains. Among interviewed respondents, 57% agreed that they had not been adequately informed about the smoke-free law; however, 90% were supportive of the ban. Nearly all respondents (97%) agreed that the law will protect workers' health, but 32% believed that the law would cause financial losses at their establishment. Indoor PM2.5 levels were hazardous (267.6 µg/m3) in venues that allowed smoking and moderate (29.6 µg/m3) in smoke-free establishments. CONCLUSIONS: In the early phase of Uganda's smoke-free law, the level of compliance in hospitality venues settings in Kampala was suboptimal. Civil society and the media have strong potential to inform and educate the hospitality industry and smokers of the benefits and requirements of the smoke-free law.

The health cost of tobacco use in Uganda.

The economic cost of tobacco use is well documented in high-income countries. It has been measured in relatively fewer low-and middle-income countries, and much less in sub-Saharan Africa despite the longstanding recognition of significant current and future health risk to people attributed by tobacco use in this region. This article fills this gap by estimating the economic cost of tobacco use in Uganda, a low-income country in sub-Saharan Africa. This study estimates the economic cost of tobacco use in Uganda using the cost-of-illnesses approach based on data collected from a survey of patients and caregivers in four major service centers in Mulago National Referral Hospital, namely, Uganda Cancer Institute, Uganda Heart Institute, Chest Clinic and Diabetic Clinic, key informant interviews and secondary sources for the year 2014. The total direct health care and non-health care cost of tobacco-related illnesses in Uganda was USD 41.56 million. The total indirect morbidity and mortality costs from the loss of productivity due to tobacco-related illnesses were USD 11.91 million and USD 73.01 million, respectively. The direct and indirect costs of tobacco use added up to USD 126.48 million, which is equivalent to 0.5% of GDP, a proportion comparable to the estimated health cost of tobacco use in other countries. The total health care cost of tobacco-related illnesses constitutes 2.3% of the national health care account which is already over-burdened with the cost of infectious diseases, limited medical personnel and infrastructure. In addition, tobacco-related illnesses heavily reduce life expectancy of tobacco users and ultimately their economic productivity. The cost of tobacco-related illnesses in Uganda far outweighs the benefits of employment and tax revenue generated from the tobacco sector. Stronger tobacco control measures need to be undertaken to reduce the disease and economic burden of tobacco use in this country.

Practices related to tobacco sale, promotion and protection from tobacco smoke exposure in restaurants and bars in Kampala before implementation of the Uganda tobacco control Act 2015.

BACKGROUND: The Word Health Organization's Framework Convention on Tobacco Control calls on parties to implement evidenced-based tobacco control policies, which includes Article 8 (protect the public from exposure to tobacco smoke), and Article 13 (tobacco advertising, promotion and sponsorship (TAPS)). In 2015, Uganda passed the Tobacco Control Act 2015 which includes a comprehensive ban on smoking in all public places and on all forms of TAPS. Prior to implementation, we sought to assess practices related to protection of the public from tobacco smoke exposure, limiting access to tobacco products and TAPS in restaurants and bars in Kampala City to inform implementation of the new law. METHODS: This was a cross-sectional study that used an observational checklist to guide observations. Assessments were: whether an establishment allows for tobacco products to be smoked on premises, offer of tobacco products for sale, observation of tobacco products for sale, tobacco advertising posters, illuminated tobacco advertisements, tobacco promotional items, presence of designated smoking zones, no-smoking signs and posters, and observation of indoor smoking. Managers of establishments were also asked whether they conducted tobacco product sales promotions within establishments. Data were collected in May 2016, immediately prior to implementation of the smoke-free and TAPS laws. RESULTS: Of the 218 establishments in the study, 17% (n = 37) had no-smoking signs, 50% (n = 108) allowed for tobacco products to be smoked on premises of which, 63% (n = 68) had designated smoking zones. Among the respondents in the study, 33.3% (n = 72) reported having tobacco products available for sale of which 73.6% (n = 53) had manufactured cigarettes as the available tobacco products. Eleven percent (n = 24) of respondents said they conducted tobacco promotion within their establishment while 7.9% (n = 17) had promotional items given to them by tobacco companies. CONCLUSION: Hospitality establishments in Kampala are not protecting the public from tobacco smoke exposure nor adequately limiting access to tobacco products. Effective dissemination of the Tobacco Control Act 2015 is important in ensuring that owners of public places are aware of their responsibility of complying with critical tobacco control laws. This would also likely increase self-enforcement among owners of hospitality establishments and public patrons of the no-smoking restrictions.