ArticleLiterature Review

Transnational tobacco companies and the mechanism of externalization: A realist synthesis

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Abstract

Externalization theory assumes that risks and costs are systematically displaced from high-income countries (HICs) to low- and middle-income countries (LMICs). We review how and why transnational tobacco companies (TTCs) influence the local circumstances of LMICs that trigger externalization mechanisms, leading to tobacco-attributable risk outcomes. Our realist synthesis of scientific evidence and gray literature identifies externalization mechanisms with risk outcomes at the level of health policy, smoking trends, and tobacco production. The results reveal the mediating role of local and global third parties and intermediaries. Externalization mechanisms produce systematic tobacco-attributable inequalities between places located in HICs and those located in LMICs.

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... Fourth, studies showed that the tobacco, alcohol, and SSB industries engage in targeted marketing, including to youth, women, and racial and ethnic minority groups [19,20,22,26,37,39,42,47,[65][66][67][68]. One of the reasons for the use of this tactic is to boost the reputation of the industry: ...
... Tobacco and SSB industry actors manipulate cost through an array of pricing strategies such as engaging in price discrimination and price promotions [36,39,50,[71][72][73][74]. These actors also use economic framings to [24,26,28,30,31,[35][36][37]48] for example, highlight their economic importance to the country in order to fight against the adoption and implementation of public health policies [24,26,[35][36][37]48]. ...
... Tobacco and SSB industry actors manipulate cost through an array of pricing strategies such as engaging in price discrimination and price promotions [36,39,50,[71][72][73][74]. These actors also use economic framings to [24,26,28,30,31,[35][36][37]48] for example, highlight their economic importance to the country in order to fight against the adoption and implementation of public health policies [24,26,[35][36][37]48]. ...
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Background Noncommunicable diseases contribute to over 70% of global deaths each year. Efforts to address this epidemic are complicated by the presence of powerful corporate actors. Despite this, few attempts have been made to synthesize existing evidence of the strategies used to advance corporate interests across industries. Given this, our study seeks to answer the questions: 1) Is there an emergent taxonomy of strategies used by the tobacco, alcohol and sugar-sweetened beverage (SSB) industries to expand corporate autonomy? 2) How are these strategies similar and how are they different? Methods Under the guidance of a framework developed by Arksey and O’Malley, a scoping review was carried out whereby six databases were searched in June 2021 to identify relevant peer-reviewed literature. To be included in this review, studies had to explicitly discuss the strategies used by the tobacco, alcohol, and/or sugar-sweetened beverage multinational corporations and be considered review articles aimed to synthesize existing evidence from at least one of the three industries. Eight hundred and fifty-eight articles were selected for full review and 59 articles were retained for extraction, analysis, and categorization. Results Results identified six key strategies the industries used: 1) influencing government policy making and implementation, 2) challenging unfavorable science, 3) creating a positive image, 4) manipulating markets, 5) mounting legal challenges, and 6) anticipating future scenarios. Despite these similarities, there are few but important differences. Under the strategy of influencing government policy making and implementation, for example, literature showed that the alcohol and SSB industries have been “privileged with high levels of participation” within international public health organizations. Conclusions Understanding how industries resist efforts to control them is important for public health advocates working to reduce consumption of and death and diseases resulting from harmful commodities. Moreover, there is a greater need for the public health community to generate consensus about how to ethically engage or not engage with industries that produce unhealthy commodities. More studies are also needed to build the evidence base of industry tactics to resist regulation, particularly in the case of SSB, and in low-and middle-income countries.
... These companies have promoted policies that avoid all environmental responsibility of the producer, and they attempt to divert public attention away from their environmental responsibilities through corporate social responsibility programmes 10 . The external environmental costs are borne by society and lowand middle-income countries in particular 11 . ...
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This paper discusses the legal aspects of the activities of transnational corporations. The relevance of the subject matter is determined by the significant impact exerted by transnational corporations on the world economy in general and on the economic situation of the country in which such corporations are registered as a subject of legal form of ownership in particular. Quality functioning of transnational corporations is an effective factor for the formation of sustainable development. This study reveals and determines the relationship between the scale of activity of transnational corporations and their legal status within the framework of both single countries and entire economic communities, the individual subjects of law of which are transnational corporations. The practical significance of this study lies in the possibility of identifying and stating key aspects that play a significant role in assessing the practical activities of transnational corporations in the context of existing legal law with the ability to use the identified patterns in specific legal practice. The results of this study can be of significant practical importance for employees in the field of legal support for the activities of transnational-scale corporations, who are faced with the need to deeply analyse the legal aspects of the activities of these organisations and provide management of such structures with timely, high-quality legal recommendations regarding the correction of the activities of these organisations in the context of the existing legal field.
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Governments increasingly aim for reducing smoking among their populations. Adolescents are an important target group of tobacco control measures, since this group is highly susceptible to influences that may cause smoking initiation. A widespread measure to reduce the number of adolescent smokers are smoke-free school policies (SFSPs) at secondary schools. However, scientific evidence about the effectiveness of SFSPs on adolescent smoking behaviour remains largely inconsistent. Some studies show a decrease, whereas other studies show no change or even an increase in adolescent smoking behaviour. The key reason for this inconsistency is that most studies use methods that were designed for making universal claims about whether and to what extent policies are effective, yet these methods are insufficiently able to take into account the complexity of the school environment. This complexity causes varying effects of SFSPs from individual to individual and from school to school, because their effects strongly depend on how relevant actors respond to the implementation of SFSPs. This dissertation therefore applies an innovative theory-driven method for evaluation, in our case the ‘realist approach’, to develop a better understanding of variations in the effectiveness of SFSPs. Two objective will be addressed: 1. Develop a comprehensive understanding of how, for whom and under which circumstances smoke-free school policies may impact adolescent smoking behaviour. 2. Develop a similar understanding about rule enforcement by school staff members. The dissertation finishes with a set of practical recommendations on how to improve the effectiveness of SFSPs and a reflection on the realist approach.
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Background: The WHO Framework Convention on Tobacco Control (WHO FCTC) has mobilised efforts among 180 parties to combat the global tobacco epidemic. This study examined the association between highest-level implementation of key tobacco control demand-reduction measures of the WHO FCTC and smoking prevalence over the treaty's first decade. Methods: We used WHO data from 126 countries to examine the association between the number of highest-level implementations of key demand-reduction measures (WHO FCTC articles 6, 8, 11, 13, and 14) between 2007 and 2014 and smoking prevalence estimates between 2005 and 2015. McNemar tests were done to test differences in the proportion of countries that had implemented each of the measures at the highest level between 2007 and 2014. Four linear regression models were computed to examine the association between the predictor variable (the change between 2007 and 2014 in the number of key measures implemented at the highest level), and the outcome variable (the percentage point change in tobacco smoking prevalence between 2005 and 2015). Findings: Between 2007 and 2014, there was a significant global increase in highest-level implementation of all key demand-reduction measures. The mean smoking prevalence for all 126 countries was 24·73% (SD 10·32) in 2005 and 22·18% (SD 8·87) in 2015, an average decrease in prevalence of 2·55 percentage points (SD 5·08; relative reduction 10·31%). Unadjusted linear regression showed that increases in highest-level implementations of key measures between 2007 and 2014 were significantly associated with a decrease in smoking prevalence between 2005 and 2015). Each additional measure implemented at the highest level was associated with an average decrease in smoking prevalence of 1·57 percentage points (95% CI −2·51 to −0·63, p=0·001) and an average relative decrease of 7·09% (−12·55 to −1·63, p=0·011). Controlling for geographical subregion, income level, and WHO FCTC party status, the per-measure decrease in prevalence was 0·94 percentage points (−1·76 to −0·13, p=0·023) and an average relative decrease of 3·18% (−6·75 to 0·38, p=0·079). This association was consistent across all three control variables. Interpretation: Implementation of key WHO FCTC demand-reduction measures is significantly associated with lower smoking prevalence, with anticipated future reductions in tobacco-related morbidity and mortality. These findings validate the call for strong implementation of the WHO FCTC in the WHO's Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020, and in advancing the UN's Sustainable Development Goal 3, setting a global target of reducing tobacco use and premature mortality from non-communicable diseases by a third by 2030. Funding: Health Canada, Canadian Institutes of Health Research, Ontario Institute for Cancer Research and Canadian Cancer Society Research Institute.
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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.
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The study aimed to describe worldwide levels and trends of tobacco control policy by comparing low and middle income countries with other income categories from 2007 to 2014 and to analyze the corresponding relation to recent changes in smoking prevalence. Policy measure data representing years 2007 to 2014 were collected from all available World Health Organization (WHO) reports on the global tobacco epidemic. Corresponding policy percentage scores (PS) were calculated based on MPOWER measures. Age-standardized smoking prevalence data for years 2010 and 2015 were collected from the WHO Global Health Observatory Data Repository. Trends of PS were analysed with respect to WHO region and OECD country income category. Scatter plots and regression analysis were used to depict the relationship between tobacco control policy of 2010 and change in smoking prevalence between 2015 and 2010 by sex and income category. Combined PS for all countries increased significantly from 47% in 2007 to 61% by 2014 (p < 0.001). When grouped by income category and region, policies were strengthened in all categories, albeit with varying progression. By 2014, tobacco control policy legislation had reached 45% in the Least Developed Countries (LDCs), 59% in Low Middle Income Countries (LMICs), 66% in Upper Middle Income Countries (UMICs) and 70% in High Income Countries (HICs). Overall, there was a negative relationship between higher policy scores and change in smoking prevalence. Although policy strengthening had been conducted between 2007 and 2014, room for considerable global improvement remains, particularly in LDCs.
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The China National Tobacco Corporation (CNTC), which produces one-third of the world’s cigarettes, is the largest tobacco company in the world. Over the past 60 years, the CNTC has been focused on supplying a huge domestic market. As the market has become increasingly saturated, and potential foreign competition looms, the company has turned to expansion abroad. This paper examines the ambitions and prospects of the CNTC to ‘go global’. Using Chinese and English language sources, this paper describes the globalisation ambitions of the CNTC, and its global business strategy focused on internal restructuring, brand development and expansion of overseas operations in selected markets. The paper concludes that the company has undergone substantial change over the past two decades and is consequently poised to become a new global player in the tobacco industry. This article is part of the special issue ‘The Emergence of Asian Tobacco Companies: Implications for Global Health Governance’.
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Objective To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing. Methods Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders. Findings Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15-1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17-5.67 and IRR: 2.52; CI: 1.23-5.17, respectively). Of the 11 842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24-76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities. Conclusion Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.
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The opening of the Thai tobacco market, following action brought by the US Trade Representative under the General Agreement on Tariffs and Trade, is seen as a key case study of the tensions between trade and health policy. Interpretations of the dispute cast it, either as an example of how trade agreements undermine national policy-making, or how governments can adopt effective public health protections compliant with international trade rules. As a UK-based company, British American Tobacco has been regarded as peripheral to this dispute. This paper argues that its close monitoring of the illegal trade during this period, the role of smuggling in the company's global business strategy, and its management of the relative supply and pricing of legal and illegal products after market opening provide a fuller understanding of the interests and roles of transnational tobacco companies and the government in this dispute. The findings have important policy implications, notably the role of effective governance in countries facing pressure to open their tobacco sectors, need to better understand corporate-level activities within an increasingly globalised tobacco industry, and need to address the intertwined legal and illegal trade in implementing the WHO Framework Convention on Tobacco Control Protocol to Eliminate Illicit Trade in Tobacco Products.
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Despite being the second largest tobacco producer in the world, Brazil does not have prevalence studies about green tobacco sickness (GTS). A cross-sectional study was carried out on a sample of Brazilian tobacco workers. The sample was described according to socio-demographic, behavioral, and occupational variables. Gender-stratified multivariate analyses examined variables associated with GTS. GTS prevalence among men in the previous month was 6.6%, while among women it was 11.9%. Among men, age, being a non-smoker, hanging tobacco sticks in the barn, harvesting wet leaves, and exposure to physical exertion were risk factors for GTS. Among women, tying hands of tobacco, transporting bales, harvesting wet leaves, having had contact with pesticides, and exposure to physical exertion were positively associated with GTS. Research is required to improve methods for GTS screening, as well as the ability to distinguish GTS from pesticide poisoning. Health professionals should be trained to diagnose and treat GTS. Am. J. Ind. Med. © 2014 Wiley Periodicals, Inc.
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Namibia is typical of low-income and middle-income countries with growing tobacco use, but with limited capacity to impose comprehensive tobacco control legislation. Despite initiating dialogue on national tobacco control policy in 1991, the country took nearly 20 years to pass the Tobacco Products Control Act. To use Namibia as a case study to illustrate challenges faced by low-income countries working to forward tobacco control legislation. Face-to-face and telephonic interviews were conducted with 13 bureaucrats and advocates currently or previously engaged in tobacco-related work in Namibia. Tobacco-related news articles from national newspapers were examined. The constitutional obligation of the government to promote public health laid the foundation for Namibia's tobacco control policy. Staff capacity constraints greatly delayed the passing of tobacco control legislation. It is unclear what influence the tobacco industry's involvement as a stakeholder had on policy; however, in at least one instance, the tobacco industry actively misled government. Namibia's ratification of the Framework Convention on Tobacco Control was instrumental in passing legislation that meets most provisions of the international treaty. The media have generally played a supportive role in pushing the government to pass tobacco control legislation. The fact that Namibia was able to pass fairly comprehensive tobacco control legislation with such meagre resources is commendable. The government must now implement the regulations that make the legislation effective. Tobacco control progress in low-income and middle-income nations can be encouraged through use of the media and improved staff and legal capacity within health ministries.
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BackgroundThis paper presents critical realism (CR) as an innovative system for research in tobacco prevention and control. CR argues that underlying mechanisms are considered and explored to ensure effective implementation of any program/policy or intervention. Any intervention or program/policy that is transposed from one country to another or one setting to another is complex. MethodsThe research was undertaken and analyzed through a critical ethnography lens using CR as a philosophical underpinning. The study relied upon the following components: original fieldwork in Nigeria including participant observation of smokers, in-depth interviews and focus groups with smokers, and in-depth interviews with health professionals working in the area of tobacco control in Nigeria.ResultsFindings from this small ethnographic study in Nigeria, suggest that Critical Realism holds promise for addressing underlying mechanism that links complex influences on smoking.ConclusionThis paper argues that understanding the underlying mechanisms associated with smoking in different societies will enable a platform for effective implementation of tobacco control policies that work in various settings.
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About this series... This series is produced by the Health, Nutrition, and Population Family (HNP) of the World Bank's Human Development Network. The papers in this series aim to provide a vehicle for publishing preliminary and unpolished results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual authors whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Homira Nassery (hnassery@worldbank.org) or HNP Advisory Service (healthpop@worldbank.org, tel 202 473-2256, fax 202 522-3234). For more information, see also www.worldbank.org/hnppublica-tions.
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To understand transnational tobacco companies' (TTCs) practices in low and middle-income countries which serve to block tobacco-control policies and promote tobacco use. Systematic review of published research on tobacco industry activities to promote tobacco use and oppose tobacco-control policies in low and middle-income countries. TTCs' strategies used in low and middle-income countries followed four main themes-economic activity; marketing/promotion; political activity; and deceptive/manipulative activity. Economic activity, including foreign investment and smuggling, was used to enter new markets. Political activities included lobbying, offering voluntary self-regulatory codes, and mounting corporate social responsibility campaigns. Deceptive activities included manipulation of science and use of third-party allies to oppose smoke-free policies, delay other tobacco-control policies, and maintain support of policymakers and the public for a pro-tobacco industry policy environment. TTCs used tactics for marketing, advertising, and promoting their brands that were tailored to specific market environments. These activities included direct and indirect tactis, targeting particular populations, and introducing new tobacco products designed to limit marketing restrictions and taxes, maintain the social acceptability of tobacco use, and counter tobacco-control efforts. TTCs have used similar strategies in high-income countries as these being described in low and middle-income countries. As required by FCTC Article 5.3, to counter tobacco industry pressures and to implement effective tobacco-control policies, governments and health professionals in low and middle-income countries should fully understand TTCs practices and counter them.
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Tobacco use is one of the major risk factors for non-communicable diseases, with a profound impact on resource-poor low-income and middle-income countries such as India, where tobacco use is high and where socioeconomic as well as health inequalities are rampant. Effective implementation of the Framework Convention on Tobacco Control requires multisectoral efforts that can fructify through integration of tobacco control into broader health and development agendas such as food and water security, environment, the right to education and human rights. The global tobacco control community will need to explore innovative partnerships beyond its traditional confines and build a global coalition that supports tobacco control by partnering with others having convergent concerns on common determinants. A firm political commitment and intersectoral coordination between government and non-government agencies is paramount in order to implement effective tobacco control programmes. Integration of tobacco control into other health and development agendas as described in this paper has the potential to contribute to the achievement of all the eight United Nations Millennium Development Goals. This paper explores why the whole of government should accord a high priority to tobacco control, and how this integration could be achieved.
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Transnational tobacco companies (TTCs) may respond to processes of regional trade integration both by acting politically to influence policy and by reorganising their own operations. The Central American Common Market (CACM) was reinvigorated in the 1990s, reflecting processes of regional trade liberalisation in Latin America and globally. This study aimed to ascertain how British American Tobacco (BAT), which dominated the markets of the CACM, sought to influence policy towards it by member country governments and how the CACM process impacted upon BAT's operations. The study analysed internal tobacco industry documents released as a result of litigation in the US and available from the online Legacy Tobacco Documents Library at http://legacy.library.ucsf.edu/. Documents were retrieved by searching the BAT collection using key terms in an iterative process. Analysis was based on an interpretive approach involving a process of attempting to understand the meanings of individual documents and relating these to other documents in the set, identifying the central themes of documents and clusters of documents, contextualising the documentary data, and choosing representative material in order to present findings. Utilising its multinational character, BAT was able to act in a coordinated way across the member countries of the CACM to influence tariffs and taxes to its advantage. Documents demonstrate a high degree of access to governments and officials. The company conducted a coordinated, and largely successful, attempt to keep external tariff rates for cigarettes high and to reduce external tariffs for key inputs, whilst also influencing the harmonisation of excise taxes between countries. Protected by these high external tariffs, it reorganised its own operations to take advantage of regional economies of scale. In direct contradiction to arguments presented to CACM governments that affording the tobacco industry protection via high cigarette tariffs would safeguard employment, the company's regional reorganisation involved the loss of hundreds of jobs. Regional integration organisations and their member states should be aware of the capacity of TTCs to act in a coordinated transnational manner to influence policy in their own interests, and coordinate their own public health and tax policies in a similarly effective way.
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To describe the approval process and implementation of the 100% smokefree law in Mexico City and a competing federal law between 2007 and 2010. Reviewed smokefree legislation, published newspaper articles and interviewed key informants. Strong efforts by tobacco control advocacy groups and key policymakers in Mexico City in 2008 prompted the approval of a 100% smokefree law following the WHO FCTC. As elsewhere, the tobacco industry utilised the hospitality sector to block smokefree legislation, challenged the City law before the Supreme Court and promoted the passage of a federal law that required designated smoking areas. These tactics disrupted implementation of the City law by causing confusion over which law applied in Mexico City. Despite interference, the City law increased public support for 100% smokefree policies and decreased the social acceptability of smoking. In September 2009, the Supreme Court ruled in favour of the City law, giving it the authority to go beyond the federal law to protect the fundamental right of health for all citizens. Early education and enforcement efforts by tobacco control advocates promoted the City law in 2008 but advocates should still anticipate continuing opposition from the tobacco industry, which will require continued pressure on the government. Advocates should utilise the Supreme Court's ruling to promote 100% smokefree policies outside Mexico City. Strong advocacy for the City law could be used as a model of success throughout Mexico and other Latin American countries.
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The business of selling cigarettes is increasingly concentrated in the hands of five tobacco companies that collectively control almost 90% of the world's cigarette market, four of which are publicly traded corporations. The economic activities of these cigarette manufacturers can be monitored through their reports to shareholders and other public documents. Reports for 2008 show that the revenues of these five companies exceeded $300 billion, of which more than $160 billion was provided to governments as taxes, and that corporate earnings of the four publicly traded companies were over $25 billion, of which $14 billion was retained after corporate income taxes were paid. By contrast, funding for domestic and international tobacco control is not reliably reported. Estimated funding for global tobacco control in 2008, at $240 million, is significantly lower than resources provided to address other highmortality global health challenges. Tobacco control has not yet benefited from the innovative finance mechanisms that are in place for HIV/AIDS, tuberculosis and malaria. The Framework Convention On Tobacco Control (FCTC) process could be used to redirect some of the earnings from transnational tobacco sales to fund FCTC implementation or other global health efforts.
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Smoke-free legislation eliminating tobacco smoke in all indoor public places and workplaces is the international standard to protect all people from exposure to secondhand smoke. Uruguay was the first country in the Americas and the first middle-income country in the world to enact a comprehensive smoke-free national legislation in March 2006. To compare air nicotine concentrations measured in indoor public places and workplaces in Montevideo, Uruguay before (November 2002) and after (July 2007) the implementation of the national legislation. Air nicotine concentrations were measured for 7-14 days using the same protocol in schools, a hospital, a local government building, an airport and restaurants and bars. A total of 100 and 103 nicotine samples were available in 2002 and 2007, respectively. Median (IQR) air nicotine concentrations in the study samples were 0.75 (0.2-1.54) microg/m(3) in 2002 compared to 0.07 (0.0-0.20) microg/m(3) in 2007. The overall nicotine reduction comparing locations sampled in 2007 to those sampled in 2002 was 91% (95% CI 85% to 94%) after adjustment for differences in room volume and ventilation. The greatest nicotine reduction was observed in schools (97% reduction), followed by the airport (94% reduction), the hospital (89% reduction), the local government building (86% reduction) and restaurants/bars (81% reduction). Exposure to secondhand smoke has decreased greatly in indoor public places and workplaces in Montevideo, Uruguay, after the implementation of a comprehensive national smoke-free legislation. These findings suggest that it is possible to successfully implement smoke-free legislations in low and middle-income countries.
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Transnational tobacco manufacturing and tobacco leaf companies engage in numerous efforts to oppose global tobacco control. One of their strategies is to stress the economic importance of tobacco to the developing countries that grow it. We analyze tobacco industry documents and ethnographic data to show how tobacco companies used this argument in the case of Malawi, producing and disseminating reports promoting claims of losses of jobs and foreign earnings that would result from the impending passage of the Framework Convention on Tobacco Control (FCTC). In addition, they influenced the government of Malawi to introduce resolutions or make amendments to tobacco-related resolutions in meetings of United Nations organizations, succeeding in temporarily displacing health as the focus in tobacco control policymaking. However, these efforts did not substantially weaken the FCTC.
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To quantify the contribution the tobacco industry has made to foreign direct investment (FDI) in the former Soviet Union (FSU) as an indicator of its political and economic leverage; to explore the impact this has had on production capacity and tobacco control in the region. Data on industry investment and its impact on cigarette production capacity were collated from industry journals, reports, and websites. Data on total FDI were obtained from the European Bank of Reconstruction and Development. By the end of 2000, transnational tobacco companies (TTCs) had invested over 2.7 billion US dollars in 10 countries of the FSU. Tobacco money as a proportion of FDI varies from 1% to over 30% in Uzbekistan. Cigarette production capacity in the factories receiving investments tripled from 146 to 416 billion cigarettes per annum and the TTCs' market share has increased from nothing to between 50-100% in the markets in which they invested. Findings suggest that the effectiveness of national tobacco control measures corresponds broadly to the nature of the political and economic transition in each country and the size of industry investment, which is determined in part by the political context. Thus more effective measures tend to be seen in democratic states with smaller or no industry investments while the least effective measures are seen in highly centralised, one party states with high levels of industry investment or those with limited governmental capacity. The entry of the TTCs at a time of major political and economic change left the FSU particularly vulnerable to industry influence. This influence was enhanced by the industry's significant contribution to FDI, their ability to take over existing state monopolies in all but the largest countries, and the lack of democratic opposition.
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Smoking Geographies provides a research-led assessment of the impact of geographical factors on smoking. The contributors uncover how geography can show us not only why people smoke but also broader issues of tobacco control, providing deeper clarity on how smoking and tobacco is ‘governed’. •The text centres on one of the most important public health issues worldwide, and a major determinant of preventable mortality and morbidity in developed and developing countries •Records the outcomes of a long-term research collaboration that brings a geographical lens to smoking behaviour •Uncovers how geography can play a part in understanding not only why people smoke but also broader issues of tobacco control •Provides a deeper understanding of how smoking and tobacco is ‘governed’, regarding where people may smoke, but also more subtle governance as a climate is produced in which smoking becomes ‘denormalised’ •Brings both quantitative and qualitative perspectives to bear on this major source of mortality and morbidity<br/
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Smokefree policies (SFPs) have diffused throughout the US and worldwide. However, the development of SFPs in the difficult policy environment of tobacco-producing states and economies worldwide has not been well-explored. In 2007, Tennessee, the third largest tobacco producer in the US, enacted the Non-Smoker Protection Act (NSPA). This study utilizes the multiple streams model to provide understanding of why and how this policy was developed by triangulating interviews with key stakeholders and legislative debates with archival documents. In June 2006, the Governor unexpectedly announced support for SFP, which created a window of opportunity for policy change. The Campaign for Healthy and Responsible Tennessee, a health coalition, seized this opportunity and worked with the administration and the Tennessee Restaurant Association to negotiate a comprehensive SFP, however, a weaker bill was used by the legislative leadership to develop the NSPA. Although the Governor and the Tennessee Restaurant Association's support generated an environment for 100 % SFP, health groups did not fully capitalize on this environmental change and settled for a weak policy with several exemptions. This study suggests the importance for proponents of policy change to understand changes in their environment and be willing and able to capitalize on these changes.
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Background: Across Europe, tobacco use is more prevalent among secondary school students attending vocational tracks compared with students attending academic tracks. The purpose of the present study is to describe trends in social inequality in daily smoking among adolescents between 2002 and 2010 by addressing both absolute social inequality (prevalence difference between vocational and academic tracks) and relative social inequality (prevalence ratio) in seven European countries. Methods: Analyses were based on data from 15-year-olds who participated in the Health Behaviour in School-aged Children study in 2002, 2006 and 2010 in Belgium, Croatia, France, Germany, Hungary, Italy and The Netherlands (total N = 32 867). Results: Overall, daily smoking decreased between 2002 and 2010 in Belgium, France, Germany and The Netherlands, increased in Croatia and remained stable in Hungary and Italy. Considerable differences in daily smoking according to educational track existed in all countries. Absolute educational inequalities increased dramatically in Croatia and Italy, while relative inequalities showed a tendency to increase in all countries (significant in Belgium and The Netherlands). Conclusions: Conclusions on social inequality in adolescent smoking may appear differently when described by absolute and relative measures. Especially the large increase in absolute educational inequalities in daily smoking in Croatia and Italy are worrisome and warrant attention from the public health domain. The findings underline the need for appropriate smoking policies and interventions in vocational schools across Europe.
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This study examined the process of smoking control policymaking in Japan, employing the Advocacy Coalition Framework (ACF) and the Policy Process Analysis (PPA). In the view of the ACF, changes in policies and policymaking are explained as resulting from the emergence of, and the competition among, two advocacy coalitions, either protobacco or antitobacco. On the other hand, the PPA conceives of the process of policy change as a set of processes and gives a closer look into the important aspects of policymaking that the ACF does not well examine.
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The WHO Framework Convention on Tobacco Control (FCTC) demonstrates the international political will invested in combating the tobacco pandemic and a newfound prominence for tobacco control within the global health agenda. However, major difficulties exist in managing conflicts with foreign and trade policy priorities, and significant obstacles confront efforts to create synergies with development policy and avoid tensions with other health priorities. This paper uses the concept of policy coherence to explore congruence and inconsistencies in objectives, policy, and practice between tobacco control and trade, development and global health priorities. Following the inability of the FCTC negotiations to satisfactorily address the relationship between trade and health, several disputes highlight the challenges posed to tobacco control policies by multilateral and bilateral agreements. While the work of the World Bank has demonstrated the potential contribution of tobacco control to development, the absence of non-communicable diseases from the Millennium Development Goals has limited scope to offer developing countries support for FCTC implementation. Even within international health, tobacco control priorities may be hard to reconcile with other agendas. The paper concludes by discussing the extent to which tobacco control has been pursued via a model of governance very deliberately different from those used in other health issues, in what can be termed 'tobacco exceptionalism'. The analysis developed here suggests that non-communicable disease (NCD) policies, global health, development and tobacco control would have much to gain from re-examining this presumption of difference.
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A four-stage model of the cigarette epidemic was proposed in 1994 to communicate the long delay between the widespread uptake of cigarette smoking and its full effects on mortality, as had been experienced in economically developed countries where cigarette smoking became entrenched decades earlier in men than in women. In the present work, the question of whether qualitative predictions from the model have matched recent trends in smoking and deaths from smoking in countries at various levels of economic development is assessed, and possible projections to the year 2025 are considered. The proportion of all deaths attributed to tobacco was estimated indirectly for 41 high-resource and medium-resource countries from 1950 to the most recent year for which data were available, generally about 2005-2009. The trends in tobacco-attributed mortality in later middle age were then projected forward to 2025, based on recent trends in tobacco-attributed mortality in early middle age. In developed countries the prevalence of smoking has continued to decrease in both sexes, although the rate of decrease has slowed and is less than that predicted by the original version of the model. Over the past 20 years the proportionate contribution of smoking to all deaths has decreased in men while continuing to increase or plateau among women. Although the proportion of all deaths at ages 35-69 that are attributed to smoking is still generally greater in men than in women, the male and female proportions are converging and will probably cross over in some high resource countries. Projections through to 2025 suggest that male and female smoking prevalence and smoking-attributed mortality will decrease in parallel in most developed countries towards lower limits that are not yet defined. In developing countries the model seems generally applicable to men but cannot predict whether or when women will begin smoking in large numbers. Modified criteria that describe the stages of the epidemic separately for men and women would be more generalisable to developing countries. The four-stage model of the cigarette epidemic still provides a reasonably useful description in many developed countries. Its relevance to developing countries could be improved by describing the stages of the epidemic separately for men and women.
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Since the launch of Tobacco Control 20 years ago, there have been several changes in the tobacco industry worldwide. The goal of this commentary is to present some of the keys changes of the past two decades. This time is marked by mergers and acquisitions that led to the existence, today, of four major transnational tobacco companies: Philip Morris International, British American Tobacco, Japan Tobacco and Imperial Tobacco. The possible role of the China National Tobacco Corporation in the world tobacco market is also discussed. In addition, in the past decade there was an increase in tobacco companies' investment in non-cigarette forms of nicotine delivery. The impact of these changes for tobacco control policy is briefly discussed.
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Indonesia is the world's fifth largest cigarette market in the world but for decades, transnational tobacco companies (TTCs) have had limited success infiltrating this market, due to their inability to compete in the kretek market. Kreteks are clove/tobacco cigarettes that most Indonesians smoke. To determine how Phillip Morris International (PMI) and British American Tobacco (BAT) have now successfully achieved a substantial market presence in Indonesia. We analyzed previously secret, tobacco industry documents, corporate reports on Indonesia operations, the Tobacco Trade press, Indonesia media, and "The Roadmap". Internal, corporate documents from BAT and PMI demonstrate that they had known for decades that kreteks are highly carcinogenic. Despite that knowledge, BAT and PMI now own and heavily market these products, as well as new more westernised versions of kreteks. BAT and PMI used their successful basic strategy of keeping cigarettes affordable by maintaining the social responsibility of smoking and opposing smoke-free workplace laws but in the 21st century, they added the acquisition of and westernisation of domestic kretek manufacturers as an additional strategy. These acquisitions allowed them to assert influences on health policy in Indonesia and to grow their business under current government policy embodied in the 2007-2020 Roadmap of Tobacco Products Industry and Excise Policy which calls for increased cigarette production by 12% over the next 15 years. PMI and Bat have successfully entered and are expanding their share in the Indonesia cigarette market. Despite the obvious and pervasive influence of the tobacco industry on policy decisions, the Indonesian government should ratify the FCTC and implement effective legislation to reduce tobacco consumption and exposure to tobacco smoke and revise the Roadmap to protect future generations of Indonesians.
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We undertook a synthesis of existing studies to re-evaluate the evidence on program mechanisms of intimate partner violence (IPV) universal screening and disclosure within a health care context by addressing how, for whom, and in what circumstances these programs work. Our review is informed by a realist review approach, which focuses on program mechanisms. Systematic, realist reviews can help reveal why and how interventions work and can yield information to inform policies and programs. A review of the scholarly literature from January 1990 to July 2010 identified 5046 articles, 23 of which were included in our study. We identified studies on 17 programs that evaluated IPV screening. We found that programs that took a comprehensive approach (i.e., incorporated multiple program components, including institutional support) were successful in increasing IPV screening and disclosure/identification rates. Four program components appeared to increase provider self-efficacy for screening, including institutional support, effective screening protocols, thorough initial and ongoing training, and immediate access/referrals to onsite and/or offsite support services. These findings support a multi-component comprehensive IPV screening program approach that seeks to build provider self-efficacy for screening. Further implications for IPV screening intervention planning and implementation in health care settings are discussed.
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Tobacco consumption is increasing in developing countries, which will bear the brunt of the tobacco epidemic in the 21st century. If current smoking patterns continue, 7 of the world's 10 million annual deaths from tobacco in 2025 will occur in developing countries. Compared with developed countries, more man and fewer women currently smoke in developing countries, but smoking among girls and women is increasing. While indigenous tobacco production and consumption remain a major problem, of particular concern is the penetration by the transnational tobacco companies, bringing with them denial of the health evidence, sophistacated advertising and promotion, threats of trade sanctions based on tobacco trade, and opposition to tobacco control measures, in particular promotional bans and tobacco tax policy. Developing countries must urgently devise and implement national tobacco control policies, but many governments have little experience in the new noncommunicable disease epidemic or in countering the transnational tobacco companies.
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The goal of the present study was to determine the variables from the theory of planned behavior that are responsible for differentiating the stages of smoking acquisition. A self-administered questionnaire was distributed to 360 secondary I level students from a possible population of 500 students. This questionnaire was designed by the researchers according to Ajzen and Fishbein's and Ajzen's recommendations regarding the predictive model variables. It also contained sociodemographic and personal variables. Data from this cross-sectional study were analyzed using multivariate analysis. The multivariate analysis of variance indicated an overall significant difference in terms of the three psychosocial variables (Pillais approximation F12,867 = 25.22; p < or = 0.000). The analyses of variance showed that the variables attitude (F4,289 = 112.25; p = 0.0001), subjective norm (F4,289 = 23.48; p = 0.0001), and perceived behavioral control (F4,289 = 87.92; p = 0.0001) contributed to differentiating the stages of smoking acquisition. The discriminant function analysis indicated that attitude (0.826) and perceived behavioral control (0.725) dominate the construct; the contribution of the subjective norm (0.375) is less important. Finally, these variables from the theory of planned behavior permitted the correct classification of 68.4% of adolescents into the stages of smoking acquisition. The application of the theory of planned behavior seems to increase understanding of the stages of smoking acquisition. The distribution of students in the five stages shows that in the advanced stages, refraining from smoking is more difficult, and that smoking advantages surpass disadvantages. These findings represent only a step toward the development of interventions aimed at warning adolescents against smoking.
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The Transnational Commercial Tobacco Companies are expanding their empires--denying the health evidence on the effects of smoking; advertising and promoting their products in every corner of the earth; obstructing government action; overpowering national monopolies; and selling more and more cigarettes. Their grip on the big markets in developing countries will become stronger as they move their agriculture and manufacturing processes out of the United States, and by 2025 there may be no tobacco grown in the United States.
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The great increase in the number of deaths attributed to cancer of the lung in the last 25 years justifies the search for a cause in the environment. An investigation was therefore carried out into the possible association of carcinoma of the lung with smoking, exposure to car and fuel fumes, occupation, etc. The preliminary findings with regard to smoking are reported. The material for the investigation was obtained from twenty hospitals in the London region which notified patients with cancer of the lung, stomach, and large bowel. Almoners then visited and interviewed each patient. The patients with carcinoma of the stomach and large bowel served for comparison and, in addition, the almoners interviewed a non-cancer control group of general hospital patients, chosen so as to be of the same sex and age as the lung-carcinoma patients. Altogether 649 men and 60 women with carcinoma of the lung were interviewed. Of the men 0.3% and of the women 31.7% were non-smokers (as defined in the text). The corresponding figures for the non-cancer control groups were : men 4.2%, women 53.3%. Among the smokers a relatively high proportion of the patients with carcinoma of the lung fell in the heavier smoking categories. For example, 26.0% of the male and 14.6% of the female lung-carcinoma patients who smoked gave as their most recent smoking habits prior to their illness the equivalent of 25 or more cigarettes a day, while only 13.5% of the male and none of the female non-cancer control patients smoked as much. Similar differences were found when comparisons were made between the maximum amounts ever smoked and the estimated total amounts ever smoked. Cigarette smoking was more closely related to carcinoma of the lung than pipe smoking. No distinct association was found with inhaling. Taken as a whole, the lung-carcinoma patients had begun to smoke earlier and had continued for longer than the controls, but the differences were very small and not statistically significant. Rather fewer lung-carcinoma patients had given up smoking. Consideration has been given to the possibility that the results could have been produced by the selection of an unsuitable group of control patients, by patients with respiratory disease exaggerating their smoking habits, or by bias on the part of the interviewers. Reasons are given for excluding all these possibilities, and it is concluded that smoking is an important factor in the cause of carcinoma of the lung. From consideration of the smoking histories given by the patients without cancer of the lung a tentative estimate was made of the number of people who smoked different amounts of tobacco in Greater London, and hence the relative risks of developing the disease among different grades of smokers were calculated. The figures obtained are admittedly speculative, but suggest that, above the age of 45, the risk of developing the disease increases in simple proportion with the amount smoked, and that it may be approximately 50 times as great among those who smoke 25 or more cigarettes a day as among non-smokers. The observed sex ratio among non-smokers (based, it must be stressed, on very few cases) can be readily accounted for if the true incidence among non-smokers is equal in both sexes. It is not possible to deduce a simple time relationship between the increased consumption of tobacco and the increased number of deaths attributed to cancer of the lung. This may be because part of the increase is apparent - that is, due to improved diagnosis - but it may also be because the carcinogen in tobacco smoke is introduced into the tobacco during its cultivation or preparation. Greater changes may have taken place in the methods involved in these processes than in the actual amount of tobacco consumed.
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To examine the strategies employed by transnational tobacco companies (TTCs) to compete more effectively compete with the dominant kretek manufacturers in Indonesia, and to consider implications of their failure. Systematic analysis of corporate documents obtained from British American Tobacco's (BAT's) Guildford depository and from industry and tobacco control websites document collections. The limited progress of the TTCs in Indonesia is best explained by the distinctive political economy of its tobacco industry. Though effective when collaborating on regulatory issues of mutual interest, TTCs have been less able than kretek manufacturers to exercise political influence where their interests conflict. Global strategies of TTCs have undergone significant local adaptation in attempting to compete in this distinctive environment. While maintaining uniformity in core brand attributes, TTCs have sought to reconcile international imagery with local norms, particularly to appeal to women. BAT unsuccessfully attempted to develop clove based products that imitated the appeal of kreteks, withdrawn following concerns about exposing the company to charges of operating double standards. The documents presented highlight the complexity of the global tobacco industry. Tobacco control efforts need to address more effectively the ongoing impact of kreteks while recognising the distinctive threats posed by TTCs.