Tackling Tobacco Advertising, Promotion, and Sponsorship in Low- and Middle-Income Countries: An Assessment of the Implementation and Reporting of Article 13 of the WHO FCTC

: (Alternative Format Thesis)

Abstract

Background: Article 13 of the Framework Convention on Tobacco Control (FCTC) outlines measures for a comprehensive ban on tobacco advertising, promotion, and sponsorship (TAPS) and provides guidelines for its implementation. However, low- and middle-income countries (LMICs) face implementation obstacles domestically. This underscores the importance of understanding the implementation context in LMICs and regularly evaluating TAPS policy implementation. The FCTC's implementation reporting system, as described in Article 21, serves as such an evaluation tool. Nevertheless, the FCTC member states’ (Parties’) utilisation of this tool has been criticised, expressing the possibility of inaccurate reporting. Thus, a deeper understanding of LMICs' challenges in Article 13 implementation and the reporting process is crucial for enhancing the existing reporting system.

Aim and Objectives: This thesis will assess the TAPS policy environment, as well as the benefits and drawbacks of the FCTC implementation reporting system for Article 13, from the LMICs' perspective. Two primary objectives were developed: to explore the current TAPS legislative environment in LMICs and to evaluate the FCTC’s reporting system in terms of facilitating the Parties to fully capture the implementation of Article 13 in LMICs.

Methods: Two distinct research projects were executed. The initial project comprised three qualitative health policy case studies conducted in LMICs (Federated States of Micronesia – FSM, Sudan, and Bangladesh), as selected through randomisation. The research utilised the health policy triangle (HPT) model, a guiding conceptual framework, which served as a comprehensive tool, investigating contextual factors influencing the policy, the processes involved in policy initiation, formulation, development, implementation, and enforcement, the content of the health policy, and the various actors involved in policy making and implementation. The READ technique (Readying the materials, Extracting data, Analysing data and Distilling findings) facilitated the systematic collection of relevant documents through searches on academic literature engines, news media databases, websites containing tobacco control policy documents, and the websites of key transnational tobacco industries, as well as national or transnational organisations focused on tobacco control. Acknowledging that the HPT model might lead to overly descriptive results, the study also employed the thematic framework approach to analyse the data. This approach enabled the identification of commonalities or differences within the investigated policy data and the extraction of descriptive and/or exploratory relationships clustered around themes.

The second project involved qualitative one-to-one interviews with National Focal Points (NFPs) -Parties’ representatives completing the implementation reports- from LMICs, to gain a deeper understanding of the completion process followed and of the challenges encountered during the completion of the WHO FCTC questionnaire section that captures the implementation of Article 13. Purposive sampling targeted 81 NFPs from this income group, while only nine participated in the interviews. The interview guide covered the participants' roles as NFPs, training, and cognitive evaluations of FCTC questionnaire responses. Thematic framework analysis was employed in five main stages (data familiarisation, initial thematic framework formulation, application of framework to the data, development of the final framework, findings interpretation).

Results: The first project revealed consistent challenges in LMICs, including non-compliance by the tobacco industry with local TAPS legislation, limited and outdated data documentation, and a call for stronger tobacco control policies. The critical roles of three actor groups -international actors (e.g., World Health Organization), health professionals and academics, and the tobacco industry- were emphasised in influencing TAPS policymaking in LMICs. Challenges in policy implementation were noted, necessitating effective monitoring, policy enforcement systems, and strong international support. Despite efforts, commonalities in the absence of specific provisions in TAPS policies were observed, indicating opportunities for improvement. Recommendations included incorporating smokeless tobacco products in definitions, explicit bans on tobacco industry corporate social responsibility activities, and provisions protecting policymaking from tobacco industry interference. Identified opportunities underscored the need for enhanced governmental monitoring, stronger regulations, academic research, actor role acknowledgment, monitoring and enforcement systems, and robust international support for driving policy changes forward.

The second project focused on understanding how Parties use the reporting system for recording the implementation of Article 13, and exploring the challenges encountered. Four key themes emerged from the findings. Firstly, participants used various resources to complete the FCTC questionnaire, with differences in the use of national legislation and supplemental approaches. Secondly, participants highlighted pre-existing struggles, such as limited human capacity and overwhelming workload, impacting the reporting process. Time constraints, language barriers, and the binary answer format of the questionnaire were identified as challenges in the third theme. The study found that participants utilised supporting mechanisms, including seeking clarity from the FCTC Secretariat and involving other government departments, to overcome challenges. Lastly, participants recommended refinements to the FCTC questionnaire, emphasising the need for clearer language, structural changes for user-friendliness, and improved support for the NFPs. The study underscored the importance of refining the questionnaire and providing enhanced support to NFPs, particularly those with limited experience, to enhance the quality and accuracy of collected data.

Discussion: The case studies offer contextually significant insights, potentially applicable to similar challenges faced by LMICs. They suggest opportunities for policy enhancements, such as improving TAPS monitoring systems, fostering advocacy partnerships with international tobacco control advocates, and strengthening overall tobacco control policies. These informed the proposed Monitoring, Advocacy, and Policy (MAP) framework. Additionally, the interview results illuminate the FCTC implementation reporting process, bridging literature criticisms with practical challenges faced by NFPs. They also pinpoint areas where tobacco control advocates and civil organisations could contribute to governmental plans and offer specific recommendations for refining data entries. These outputs informed the creation of a supplementary guide to strengthen the FCTC Article 13 implementation reporting process.

Conclusion: This dissertation underscores the urgency of persistent efforts to overcome the existing obstacles hindering the effective implementation of Article 13 in LMICs. The insights gained from the FCTC reporting tool inform the global tobacco control agenda, potentially leading to substantial advancements in public health outcomes. Hence, integrating the recommendations from the NFPs into future iterations of the FCTC implementation reporting system is crucial.

Date of Award	17 Jan 2024
Original language	English
Awarding Institution	University of Bath
Supervisor	Jo Cranwell (Supervisor), Bryan Clift (Supervisor), Sally Adams (Supervisor) & Becky Freeman (Supervisor)