Building a Systems Map: Applying Systems Thinking to Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures. METHODS: Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society, public office and global governance organisations. Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map. RESULTS: The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policymaking: 1) direct access to public sector decision-makers; 2) creation of confusion and doubt about policy decisions; 3) corporate prioritisation of commercial profits and growth; 4) industry leveraging the legal and dispute settlement processes; and 5) industry leveraging policymaking, norms, rules, and processes. CONCLUSION: UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions future work.

Complex Interventions for a Complex System? Using Systems Thinking to Explore Ways to Address Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored. METHODS: Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data. RESULTS: Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map's pathways that reduce the ability of UCIs to influence policy, e.g., reform policy financing; regulate public-private partnerships; reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and GDP growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (i.e., difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (i.e., coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership). CONCLUSION: A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied to different parts of the system synchronously. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

Topic prediction for tobacco control based on COP9 tweets using machine learning techniques.

The prediction of tweets associated with specific topics offers the potential to automatically focus on and understand online discussions surrounding these issues. This paper introduces a comprehensive approach that centers on the topic of "harm reduction" within the broader context of tobacco control. The study leveraged tweets from the period surrounding the ninth Conference of the Parties to review the Framework Convention on Tobacco Control (COP9) as a case study to pilot this approach. By using Latent Dirichlet Allocation (LDA)-based topic modeling, the study successfully categorized tweets related to harm reduction. Subsequently, various machine learning techniques were employed to predict these topics, achieving a prediction accuracy of 91.87% using the Random Forest algorithm. Additionally, the study explored correlations between retweets and sentiment scores. It also conducted a toxicity analysis to understand the extent to which online conversations lacked neutrality. Understanding the topics, sentiment, and toxicity of Twitter data is crucial for identifying public opinion and its formation. By specifically focusing on the topic of "harm reduction" in tweets related to COP9, the findings offer valuable insights into online discussions surrounding tobacco control. This understanding can aid policymakers in effectively informing the public and garnering public support, ultimately contributing to the successful implementation of tobacco control policies.

Seeking to be seen as legitimate members of the scientific community? An analysis of British American Tobacco and Philip Morris International's involvement in scientific events.

INTRODUCTION: For decades, tobacco companies manipulated and misused science. They funded and disseminated favourable research and suppressed research that showed the harms of their products, deliberately generating misinformation. While previous work has examined many of the practices involved, their engagement in scientific events has so far not been systematically studied. Here, we examine the involvement of British American Tobacco (BAT) and Philip Morris International (PMI) in scientific events, including conferences, symposia and workshops. METHODS: Our analysis involved two steps. First, we collected all available data PMI and BAT provided on their websites to identify events. Second, we extracted information about the nature of tobacco industry involvement from event websites and materials. RESULTS: We identified 213 scientific events that BAT and/or PMI representatives attended between April 2012 and September 2021. Most events took place in high-income countries in Europe and North America. They covered a diverse range of fields, including toxicology (n=60, 28.1%), medicine (n=25, 11.7%), biology (n=24, 11.3%), chemistry (n=23, 10.8%) and aerosol science (n=18, 8.5%), as well as dentistry (n=9, 4.2%), pharmaceutical science (n=8, 3.8%) and computing (n=8, 3.8%). We identified 356 posters provided by BAT and PMI that linked to 118 events (55.4%) as well as 77 presentations from 65 events (30.5%). Industry involvement through sponsorship (nine events), exhibition (three events) or organising committee (one event) was rare. CONCLUSION: BAT and PMI representatives attended a large number and wide range of scientific events. Given that scientific events could be a crucial platform for building connections in the scientific sphere and disseminating industry's messages, this work highlights the importance of denormalising the tobacco industry's involvement in scientific events.

Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh.

BACKGROUND: In Bangladesh, the 2013 Amendment of the Tobacco Control Act made graphic health warnings (GHWs) on the upper 50% of all tobacco packs obligatory. However, at the time of writing (May 2022), GHWs are still being printed on the lower 50% of packs. This paper seeks to explore how the tobacco industry undermined the development and implementation of GHWs in Bangladesh, a country known for a high level of tobacco industry interference (TII) that has rarely been examined in the peer-reviewed literature. METHODS: Analysis of print and electronic media articles and documents. RESULTS: Cigarette companies actively opposed GHWs, while bidi companies did not. The primary strategy used to influence the formulation and delay the implementation of GHWs was direct lobbying by the Bangladesh Cigarette Manufacturers' Association and British American Tobacco Bangladesh. Their arguments stressed the economic benefits of tobacco to Bangladesh and sought to create confusion about the impact of GHWs, for example, claiming that GHWs would obscure tax banderols, thus threatening revenue collection. They also claimed technical barriers to implementation-that new machinery would be needed-leading to delays. Tensions between government bodies were identified, one of which (National Board of Revenue)-seemingly close to cigarette companies and representing their arguments-sought to influence others to adopt industry-preferred positions. Finally, although tobacco control advocates were partially successful in counteracting TII, one self-proclaimed tobacco control group, whose nature remains unclear, threatened the otherwise united approach. CONCLUSIONS: The strategies cigarette companies used closely resemble key techniques from the well-evidenced tobacco industry playbook. The study underlines the importance of continuing monitoring and investigations into industry conduct and suspicious actors. Prioritising the implementation of WHO Framework Convention on Tobacco Control Article 5.3 is crucial for advancing tobacco control, particularly in places like Bangladesh, where close government-industry links exist.

Document analysis of the Foundation for a Smoke-Free World's scientific outputs and activities: a case study in contemporary tobacco industry agnogenesis.

BACKGROUND: Tobacco corporation Philip Morris International launched the Foundation for a Smoke-Free World (FSFW), a purportedly independent scientific organisation, in 2017. We aimed to systematically investigate FSFW's activities and outputs, comparing these with previous industry attempts to influence science, as identified in the recently developed typology of corporate influence on science, the Science for Profit Model (SPM). DESIGN: We prospectively collected data on FSFW over a 4-year period, 2017-2021, and used document analysis to assess whether FSFW's activities mirror practices tobacco and other industries have historically used to shape science in their own interests. We used the SPM as an analytical framework, working deductively to search for use of the strategies it identifies, and inductively to search for any additional strategies. RESULTS: Marked similarities between FSFW's practices and previous corporate attempts to influence science were observed, including: producing tobacco industry-friendly research and opinion; obscuring industry involvement in science; funding third parties which denigrate science and scientists that may threaten industry profitability; and promoting tobacco industry credibility. CONCLUSIONS: Our paper identifies FSFW as a new vehicle for agnogenesis, indicating that, over 70 years since the tobacco industry began to manipulate science, efforts to protect science from its interference remain inadequate. This, combined with growing evidence that other industries are engaging in similar practices, illustrates the urgent need to develop more robust systems to protect scientific integrity.

What Can Current Biomarker Data Tell Us About the Risks of Lung Cancer Posed by Heated Tobacco Products?

INTRODUCTION: Heated tobacco products (HTPs) are marketed as less harmful alternatives to cigarettes, but the lung cancer risk of HTPs is unknown. In the absence of epidemiological data, assessing the risks of HTPs relies on biomarker data from clinical trials. This study examined existing biomarker data to determine what it tells us about the lung cancer risk posed by HTPs. AIMS AND METHODS: We identified all biomarkers of exposure and potential harm measured in HTP trials and evaluated their appropriateness based on ideal characteristics for measuring lung cancer risk and tobacco use. The effects of HTPs on the most appropriate biomarkers within cigarette smokers switched to HTPs and compared to continued cigarette smoking or cessation were synthesized. RESULTS: Sixteen out of eighty-two biomarkers (7 exposure and 9 potential harm) measured in HTP trials have been associated with tobacco use and lung cancer, dose-dependently correlated with smoking, modifiable upon cessation, measured within an appropriate timeframe, and had results published. Three of the exposure biomarkers significantly improved in smokers who switched to HTPs and were not significantly different from cessation. The remaining 13 biomarkers did not improve-in some instances worsening upon switching to HTPs-or were inconsistently affected across studies. There were no appropriate data to estimate the lung cancer risk of HTPs in non-smokers. CONCLUSIONS: The appropriateness of existing biomarker data in assessing lung cancer risk of HTPs, both relative to cigarettes and their absolute risk, is limited. Furthermore, findings on the most appropriate biomarkers were conflicting across studies and largely showed no improvement following a switch to HTPs. IMPLICATIONS: Biomarker data are fundamental to assessing the reduced risk potential of HTPs. Our evaluation suggests much of the existing biomarker data on HTPs is inappropriate for determining the risk of lung cancer posed by HTPs. In particular, there is a paucity of data on the absolute lung cancer risk of HTPs, which could be obtained from comparisons to smokers who quit and never smokers exposed to or using HTPs. There is an urgent need for further exploration of the lung cancer risks posed by HTPs, via clinical trials and, in the long-term, confirmation of these risks via epidemiological studies. However, careful consideration should be given to biomarker selection and study design to ensure both are appropriate and will provide valuable data.

"They try to suppress us, but we should be louder": a qualitative exploration of intimidation in tobacco control.

BACKGROUND: Tobacco control advocates and researchers face powerful opponents who go to great lengths to protect their interests. While threats and attacks are documented in the grey literature, research into intimidation remains scarce. Building on previous exploratory research, this study seeks to offer in-depth insights into experiences of intimidation in the global tobacco control community. METHODS: Using qualitative description, we conducted a focus group and semi-structured interviews with tobacco control advocates and researchers to explore their experiences, including forms of, and responses to, intimidation, and ways forward. Data were analysed using qualitative content analysis. RESULTS: Twenty-nine individuals from across the globe participated in the study. They reported several forms of intimidation including attacks in the media; online harassment; legal threats; non-legal threats, including death threats; Freedom of Information requests; perceived or actual surveillance; as well as burglary and theft. Responses included non-action (i.e. ignoring attacks); withdrawal (i.e. abandoning a project, area or field); defensive adaptation, for example through self-censorship; and offensive measures, including exposing attacks or filing complaints. Responses were shaped by several factors, including type and level of support from within internal and external networks; as well as an individual's mindset, skills and experiences; and state-civil society relations. Participants suggested several measures that could help address intimidation: 1) report and monitor intimidation; 2) (better) prepare individuals through awareness raising and training (e.g. IT security, legal); 3) support those in need through legal advice, a peer-support network and involvement in response; and 4) look beyond tobacco control to learn and build connections. CONCLUSION: Intimidation is a significant challenge to tobacco control that needs urgent attention. This study suggests measures to address intimidation that require commitment from, and collaboration amongst, multiple actors including governments, international organisations, funders, researchers and civil society. Moreover, collective action beyond tobacco control is needed to not only manage but move beyond intimidation.

How has the tobacco industry passed tax changes through to consumers in 12 sub-Saharan African countries?

INTRODUCTION: Tobacco taxation is only effective in reducing consumption when it is translated into higher prices. This study aims to investigate to what extent the tobacco industry (TI) passes tax increases over to consumers by increasing the retail price of cigarettes in 12 sub-Saharan African (SSA) countries. METHODS: African Cigarette Prices Project and WHO's Global Tobacco Epidemic Reports data were used to calculate the rate of tax pass-through by decomposing the retail price of cigarettes into tax and net prices between 2016 and 2020. Percentage change in net price was used to identify industry pricing behaviour, in both packs and single-stick sales. TI pricing strategies were examined by country, producer type, producers, and cigarette price segment. RESULTS: There were mixed TI strategies, with taxes primarily overshifted (Botswana, Madagascar, Tanzania, Zimbabwe), undershifted (Ethiopia, Lesotho, Mozambique, Namibia, South Africa, Zambia) or a mix of both (Malawi, Nigeria). The detail varied between countries, over time, and between the different brands/segments offered. Patterns for single-stick sales were broadly similar to that of packs but with some differences observed in particular countries/years. Pricing strategies for the various transnational tobacco companies and domestic producers were similar but the changes in net price for the latter were larger. The country tax level/type and the size of tax change did not seem to be an obvious influence. CONCLUSION: This paper provides an overview of TI pricing strategies in response to tax increases in SSA. Governments must monitor how the TI responds to tax changes to ensure that tax increases are effective in impacting price.

Corporate Political Activity: Taxonomies and Model of Corporate Influence on Public Policy.

BACKGROUND: Non-communicable diseases (NCDs) kill 41 million people a year. The products and services of unhealthy commodity industries (UCIs) such as tobacco, alcohol, ultra-processed foods and beverages and gambling are responsible for much of this health burden. While effective public health policies are available to address this, UCIs have consistently sought to stop governments and global organisations adopting such policies through what is known as corporate political activity (CPA). We aimed to contribute to the study of CPA and development of effective counter-measures by formulating a model and evidence-informed taxonomies of UCI political activity. METHODS: We used five complementary methods: critical interpretive synthesis of the conceptual CPA literature; brief interviews; expert co-author knowledge; stakeholder workshops; testing against the literature. RESULTS: We found 11 original conceptualisations of CPA; four had been used by other researchers and reported in 24 additional review papers. Combining an interpretive synthesis of all these papers and feedback from users, we developed two taxonomies - one on framing strategies and one on action strategies. The former identified three frames (policy actors, problem, and solutions) and the latter six strategies (access and influence policy-making, use the law, manufacture support for industry, shape evidence to manufacture doubt, displace, and usurp public health, manage reputations to industry's advantage). We also offer an analysis of the strengths and weaknesses of UCI strategies and a model that situates industry CPA in the wider social, political, and economic context. CONCLUSION: Our work confirms the similarity of CPA across UCIs and demonstrates its extensive and multi-faceted nature, the disproportionate power of corporations in policy spaces and the unacceptable conflicts of interest that characterise their engagement with policy-making. We suggest that industry CPA is recognised as a corruption of democracy, not an element of participatory democracy. Our taxonomies and model provide a starting point for developing effective solutions.

The use of participatory systems mapping as a research method in the context of non-communicable diseases and risk factors: a scoping review.

CONTEXT: Participatory systems mapping is increasingly used to gain insight into the complex systems surrounding non-communicable diseases (NCDs) and their risk factors. OBJECTIVES: To identify and synthesize studies that used participatory systems mapping in the context of non-communicable diseases. DESIGN: Scoping review. ELIGIBILITY CRITERIA: Peer-reviewed studies published between 2000 and 2022. STUDY SELECTION: Studies that focused on NCDs and/or related risk factors, and included participants at any stage of their system's mapping process, were included. CATEGORIES FOR ANALYSIS: The main categories for analysis were: (1) problem definition and goal-setting, (2) participant involvement, (3) structure of the mapping process, (4) validation of the systems map, and (5) evaluation of the mapping process. RESULTS: We identified 57 studies that used participatory systems mapping for a variety of purposes, including to inform or evaluate policies or interventions and to identify potential leverage points within a system. The number of participants ranged from 6 to 590. While policymakers and professionals were the stakeholder groups most often included, some studies described significant added value from including marginalized communities. There was a general lack of formal evaluation in most studies. However, reported benefits related mostly to individual and group learning, whereas limitations described included a lack of concrete actions following from systems mapping exercises. CONCLUSIONS: Based on the findings of this review, we argue that research using participatory systems mapping would benefit from considering three different but intertwined actions: explicitly considering how different participants and the power imbalances between them may influence the participatory process, considering how the results from a systems mapping exercise may effectively inform policy or translate into action, and including and reporting on evaluation and outcomes of the process, wherever possible.

Advocacy counterstrategies to tobacco industry interference in policymaking: a scoping review of peer-reviewed literature.

BACKGROUND: There has been remarkable tobacco control progress in many places around the globe. Tobacco industry interference (TII) has been identified as the most significant barrier to further implementation of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Civil society has been recognised as a key actor in countering TII. While TII has been extensively studied for several decades now, there is little research that focuses on counteractions to limit it and their effectiveness to do so. This scoping review seeks to map the peer-reviewed literature on civil society's activities of countering TII in policymaking to identify common counterstrategies and assess their effectiveness. METHODS: Data sources: We searched Embase, IBSS, JSTOR, PubMed, Science Direct, Scopus and Web of Science using the following terms: ("Tobacco industry" OR "Tobacco compan*") AND. ("corporate political activity" OR "CPA" OR "lobbying" OR "interference") AND ("advoca*" OR "counter*" OR "activi*"), without time or language restrictions. STUDY SELECTION: Our selection criteria included peer-reviewed studies that were written in English, German, or Spanish that drew on primary data and/or legal and policy documents and reported at least one specific example of civil society members or organisations countering tobacco industry action-based strategies. DATA EXTRACTION: Advocates' counterstrategies were analysed inductively and countered industry strategies were analysed using the Policy Dystopia Model (PDM). Perceptions of effectiveness of countering attempts were analysed descriptively. RESULTS: We found five common counterstrategies among 30 included papers covering five WHO regions; 1. Exposing industry conduct and false claims; 2. Accessing decision-makers; 3. Generating and using evidence; 4. Filing a complaint or taking legal action; 5. Mobilising coalition and potential supporters. These counterstrategies were used to work against a wide range of industry strategies, which are captured by five action-based strategies described in the PDM (Coalition Management, Information Management, Direct Access and Influence, Litigation, Reputation Management). While some studies reported the outcome of the countering activities, their impact remained largely underexplored. CONCLUSION: The review shows that peer-reviewed literature documenting how civil society actors counter TII is scarce. It suggests that advocates employ a range of strategies to counter TII in its different forms and use them flexibly. More work is needed to better understand the effects of their actions. This could stimulate discussions about, and facilitate learning from, past experiences and help to further enhance advocates' capacity.

Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations.

Most public health research on the commercial determinants of health (CDOH) to date has focused on a narrow segment of commercial actors. These actors are generally the transnational corporations producing so-called unhealthy commodities such as tobacco, alcohol, and ultra-processed foods. Furthermore, as public health researchers, we often discuss the CDOH using sweeping terms such as private sector, industry, or business that lump together diverse entities whose only shared characteristic is their engagement in commerce. The absence of clear frameworks for differentiating among commercial entities, and for understanding how they might promote or harm health, hinders the governance of commercial interests in public health. Moving forward, it is necessary to develop a nuanced understanding of commercial entities that goes beyond this narrow focus, enabling the consideration of a fuller range of commercial entities and the features that characterise and distinguish them. In this paper, which is the second of three papers in a Series on commercial determinants of health, we develop a framework that enables meaningful distinctions among diverse commercial entities through consideration of their practices, portfolios, resources, organisation, and transparency. The framework that we develop permits fuller consideration of whether, how, and to what extent a commercial actor might influence health outcomes. We discuss possible applications for decision making about engagement; managing and mitigating conflicts of interest; investment and divestment; monitoring; and further research on the CDOH. Improved differentiation among commercial actors strengthens the capacity of practitioners, advocates, academics, regulators, and policy makers to make decisions about, to better understand, and to respond to the CDOH through research, engagement, disengagement, regulation, and strategic opposition.

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.

Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Extent of illicit cigarette market from single stick sales in Ghana: findings from a cross-sectional survey.

OBJECTIVE: This study aims to measure the extent of illicit cigarette consumption from single stick sales, to determine the nature and types of illicit cigarettes present in Ghana, and to identify the factors associated with illicit cigarette consumption in Ghana. DESIGN: A cross-sectional study using empty cigarette packs generated by 1 day's single stick cigarette sales collected from cigarette vendors. SETTING: Five large cities (Accra, Kumasi, Takoradi, Tamale and Bolgatanga) and three border towns (Aflao, Paga/Hamele and Elubo) in the northern, middle and coastal belt of Ghana. PROCEDURE AND PARTICIPANTS: Ten areas were randomly selected in each city/town, and all shops selling cigarettes within 1 km of the central point were surveyed. OUTCOME MEASURES: (1) Estimates of the share of illicit cigarette packs in the total cigarette sales from vendors selling single stick cigarettes in Ghana; (2) nature and types of illicit cigarette packs; (3) factors associated with illicit cigarette sales in Ghana. RESULTS: Of a total of 4461 packs, about 20% (95% CI 18.3 to 20.7) were found to be illicit. Aflao (Ghana-Togo border) and Tamale (Ghana-Burkina Faso border) had the highest percentage of illicit cigarette sales at 99% and 46%, respectively (p<0.001). Over half of the illicit packs originated from Togo (51%), followed by Nigeria (15%) and then Cote d'Ivoire (10%). Adjusted and unadjusted logistic regression models indicated that convenience stores, border towns, pack price and the northern zone had higher odds of illicit cigarette sales. CONCLUSION: To effectively tackle illicit cigarettes, market surveillance and strengthening supply chain control are required, particularly at the border towns and the northern region of the country.

Content analysis of Dutch newspaper coverage of three tobacco control policies, 2017-2019.

OBJECTIVES: News media coverage can influence support for and implementation of tobacco control policies. This research aims to analyse and compare newspaper coverage of newly implemented policies: a substantial tobacco tax increase, point-of-sale display ban and plain packaging. DESIGN: We conducted a content analysis of articles covering the three policies from ten national Dutch newspapers. Articles published between November 2017 and November 2019 were coded for type and tone. The policy dystopia model was used to code arguments opposing the policies. Tobacco industry appearances in news articles were also analysed for frequency and type. RESULTS: A total of 134 news articles were analysed, of which the industry appeared in 28%. The majority of coverage was neutral in tone, although among articles that were coded as expressing a positive or negative tone, plain packaging and the point-of-sale ban were portrayed more negatively than positively. Negative coverage was predominantly accounted for by industry presence. Arguments opposing the policies focused on negative economic consequences, challenging the need for policy and adverse consequences for retailers for tax, plain packaging and the point-of-sale display ban, respectively. We identified six specific new arguments that fit within existing domains of the policy dystopia model. CONCLUSIONS: The tobacco industry and its allies still appear in a substantial proportion of news articles in relation to tobacco policy. This study identifies contemporary industry arguments against tobacco control policies in Europe which, alongside the policy dystopia model, can be used to predict and counter the tobacco industry's future attempts to oppose policies.

Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa.

BACKGROUND: In 2018, South Africa opened public consultations on its newly proposed tobacco control bill, resulting in substantial public debate in which a range of arguments, either in favour of or against the Bill, was advanced. These were accompanied by the recurring discussions about the annual adjustments in tobacco taxation. This study uses the concept of framing to examine the public debate in South African print media on the potential effects of the legislation, as well as tobacco tax regulations, between their proponents and detractors. METHODS: A systematic search of news articles using multiple data sources identified 132 media articles published between January 2018 and September 2019 that met the inclusion criteria. RESULTS: Seven overarching frames were identified as characterising the media debate, with the three dominant frames being Economic, Harm reduction and vaping, and Health. The leading Economic frame consisted primarily of arguments unsupportive of tobacco control legislation. Economic arguments were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks-several of which have been identified as front groups or third-party lobbyists for the tobacco industry. CONCLUSION: The dominance of economic arguments opposing tobacco control legislation risks undermining tobacco control progress. Local and global tobacco control advocates should seek to build relationships with media, as well as collate and disseminate effective counterarguments to those advanced by the industry.