Background
The World Health Organization’s Framework Convention on Tobacco Control (FCTC), enforced on February 27, 2005 was the first global public health treaty [
1]. This treaty emerged after years of effort to spearhead an international approach to tobacco regulation that would slow the rapid growth of tobacco use. The treaty stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on public health. Although the FCTC has been popular, with 180 countries currently ratifying the treaty [
2], little is known about how low- and middle-income countries responded to the FCTC to modify their tobacco policies and what other contextual issues influenced the timeliness of countries’ responses [
3].
The FCTC solidified tobacco use as a public health epidemic [
1,
3,
4]. As evidence continues to accumulate about the global impact of tobacco consumption on non-communicable diseases (NCDs), efforts to include tobacco control have increased. The FCTC requires all participating countries to reduce this impact through various initiatives, including national programs on tobacco control; measures to protect people from second-hand tobacco smoke in public places; health warnings on tobacco products; restrictions on tobacco advertising; and prohibition of sale of tobacco products to minors [
5]. Tobacco companies joined forces to oppose the FCTC and countries’ implementation of tobacco control policies, including proposing alternative language, actively lobbying against the framework, employing deception, and selectively marketing and promoting products to maintain the social acceptability of tobacco use [
3,
6‐
8]. Some of the most devastating impacts of tobacco prevalence have been witnessed in sub-Saharan Africa, where developing nations are still struggling to fund a response to HIV and AIDS and other infectious diseases.
The history of the tobacco crop in sub-Saharan Africa today will illuminate its complex role. In the early twentieth century, a rise of African fire-cured tobacco production in the central region increased the number of Africans participating in share-cropping contracts with Europe [
9,
10]. These agreements yielded financial gains for the farmers that some African countries still rely on today. Currently, Malawi is one of only two countries in the world that depend on tobacco leaf production for most of its export earnings [
10]. Tobacco industries have used this reliance to their advantage in responding to a growing number of regulations and control initiatives. For example, in response to early WHO tobacco control programs at the beginning of the twenty-first century, the International Tobacco Growers Association lamented that poor African farmers [
9] would suffer if tobacco regulation was successful [
6]. An additional element of tobacco use in sub-Saharan Africa is its rapid growth that challenges governments to keep up with regulations to control and tax its use in the interest of protecting the public. Between 1995 and 2000, cigarette consumption increased by 38% in Africa [
11]. By 2030, it is projected that 70% of the estimated 10 million global deaths from tobacco will occur in developing countries such as those in sub-Saharan Africa [
11].
The WHO’s “best buys” delineate specific, low-cost, population-level interventions that, if scaled up, could reduce harmful tobacco and alcohol use, as well as unhealthy diets and physical inactivity [
12]. These “best buys” hold specific promise for low and middle income countries such as many of those in sub-Saharan Africa. WHO “best buy” interventions for tobacco are, briefly, the creation of policies for tax increases on tobacco products, smoke-free indoor workplaces and public places, bans on tobacco advertising, promotion and sponsorship, and health information and warnings. Significant examinations of global tobacco policy (e.g., the International Tobacco Control Policy Project [
13], have generally not included African countries, and given recent findings that policy implementation of the FCTC demand reduction measures is associated with reduction in tobacco use [
14], it is especially important to assess the adoption of tobacco policies in Africa [
11].
This paper describes how six sub-Saharan countries responded to the FCTC call for action on tobacco control by detailing the context, timelines, key actors, and strategies in the formulation and implementation of policies in response to the FCTC. Understanding these elements can provide insight for accelerating international mobilization to reduce and prevent NCD prevalence. In each country we present the (a) tobacco situation (production and use), (b) the FCTC adoption process (year of ratification and period taken to come up with a policy, what influenced the process), (c) the actors and industry involvement, (d) implementation of FCTC policies and WHO best buys for tobacco control.
Methods
Methods overview
The Analysis of Non-Communicable Disease Prevention Policies in Africa (ANPPA) study [
15] employed a multiple-case study design [
16] to assess policy and practice for all WHO “best buy” interventions on tobacco use, unhealthy diet, physical inactivity, and harmful alcohol use in six sub-Saharan countries: Kenya, Malawi, Nigeria, Cameroon, South Africa, and Togo. The ANPPA study was designed to generate evidence on how—and the extent to which—multi-sectoral action informs policy formulation and implementation of NCD prevention “best buy” interventions. Walt and Gilson framework of policy analysis [
17] was used to guide ANPPA. The framework acknowledges the non-linearity of the policy process as well as the incremental nature of policy-making. Walt and Gilson’s framework focuses on four factors: policy (a) content, (b) actors, (c) processes, and (d) context [
17].
This paper reports only on data collected on tobacco. Each country, therefore, becomes a case with its own unique approach to ratifying the FCTC and establishing policies to support tobacco control. For each case, we apply the same methods to identify differences in each country’s processes. Each case includes two primary sources of data: (1) a review of documents related to the policy formulation process and (2) key informant interviews with informants who either participated or should have participated in the policy process.
The ANPPA study was coordinated by the African Population and Health Research Center (APHRC). See Juma et al. [
15] for more information on the application process and study teams.
Document reviews
Teams conducted document reviews to describe the policy context and content, identify existing policies for their consistency with WHO “best buy” interventions, and understand the policy development processes and implementation status. Policy documents included were those that focused on NCD prevention (including acts and laws, strategic plans, guidelines, and government directives), reviews and case studies of multi-sectoral action (MSA) in successful policy formulation and implementation at a national level. Examples of policy documents included are: ministry website materials such as policy documents, strategic plans, program plans, guidelines, protocols; parliamentary records, or debates; local print media for references to policy changes, often as part of speeches by government officials; meeting minutes, activity reports, and drafts of policy statements, internal and external memos, meeting agendas, and other communications; academic journal articles; and relevant donor or non-governmental organization and development partner websites for NCD program reports. Researchers extracted data from documents including the years in which relevant policy changes occurred and the events leading up to those decisions. Some key documents date back to the 1970s (e.g., national plans and reports).
Key informant interview participants were selected based on their expected or actual role in each country’s NCD policy formulation and implementation. Participants were selected using a combination of purposive and snowball sampling [
18]. First, a broad segment of sectors (e.g., health, education, finance) and institutions (e.g., ministry officials, directors) were identified for inclusion. Next, appropriate individuals within those sectors and institutions were identified to purposively include both government and non-government (e.g., community organization, industry) actors. After key informants were identified, researchers asked them to identify additional prospective study participants who had knowledge of policy formulation and implementation. Participants were contacted through an initial telephone or email contact, and a total of 202 were interviewed across six countries [
19].
APHRC and the study teams collaboratively developed interview guides during the first methodology workshop. Interview guides were informed by Walt and Gilson’s framework of policy analysis [
17] and included questions for each of the four key “best buy” interventions, including the context in which the policy was developed, the policy content, actors involved in the process, and the implementation status of each policy. In addition, questions addressed how MSA was employed (or not), the processes undertaken to ensure MSA, the challenges encountered, what worked, and what did not work. During field-worker training, each team piloted the guide to obtain feedback on the questions and interview structure, and the interview guide was revised based on feedback from the pilots. Each country then used the final interview guide with minor adjustments to fit their context if necessary.
Prior to the interview, the interviewer explained the purpose of the study, risks and benefits to participating, the right to withdraw at any time without penalty, and confidentiality; participants provided verbal or written documentation of consent to participate and to be digitally recorded.
Transcripts were uploaded into the qualitative data management software NVivo coded using a codebook based on Walt and Gilson’s framework of policy analysis [
17] and the framework method of qualitative analysis, a type of thematic or content analysis which guides the application of a framework to analyse qualitative data [
20]. Data associated with tobacco policy formulation from all six countries were analysed for this multiple case study.
Discussion
Countries varied widely on their timelines for addressing tobacco control, with the earliest tobacco-related policies in the mid-twentieth century (e.g., Nigeria, 1951; Malawi, 1970) and others developing policies only around the time of the FCTC in the mid-2000s (Togo). Earlier attention to tobacco-related policies often was more about commerce and agriculture than public health and did not relate to the country’s implementation of FCTC policies (e.g., Malawi has not yet ratified the FCTC). Most countries developed piecemeal legislation starting in the 1990s and early 2000s, with the FCTC providing a strong boost as countries began to ratify it in the mid to late 2000s. The process for adopting tobacco policies focused on public health and consistency with “best buy” interventions was greatly motivated by FCTC adoption. It brought significant international focus on tobacco; countries’ treaty signing provided additional energy for the study to approve legislation so as not to be seen as falling behind on the world stage.
Countries demonstrated high variability in their socio-political contexts: (a) tobacco was a significant cash crop that contributed to national employment and revenue (Cameroon, Malawi), (b) leadership demonstrated connections or interests in tobacco industries that reduced political will for tobacco control (Nigeria, apartheid South Africa, Togo), (c) limited resources were available for NCD prevention, given countries’ political upheaval or communicable disease challenges (Cameroon, Kenya, Malawi, Nigeria, South Africa, Togo), (d) specific high-profile champions in government advocated for tobacco control (South Africa, Kenya, Nigeria), and (e) tobacco industries and their interests were strongly against tobacco control legislation (Cameroon, Kenya, Malawi, South Africa, Nigeria). This variability in contexts also influenced the countries’ success implementing FCTC and WHO “best buys” on tobacco control.
Multiple actors engaged in deliberations about tobacco policies [
19]. Most countries’ health ministries led the process of evaluating FCTC guidelines and preparing policies with other ministries, NGOs, civil society organisations, and academics [
23,
25,
41,
43,
44]. These groups generally supported tobacco control policies. The extent to which stakeholders were involved varied from nominal involvement to providing data, testimony, or lobbying for country-specific measures.
Countries struggled with whether or how to involve the tobacco industry in their selected stakeholder meetings; for instance, in South Africa, the constitution requires stakeholder representation, and the tobacco industry sued to require the government to recognize its inclusion as a stakeholder [
41]. All countries reported significant interference from the tobacco industry in enacting tobacco control policies, with some countries also having labour groups or tobacco farmers opposing tobacco control policies (Malawi, Nigeria). This is similar to industry efforts to derail the FCTC prior to enactment and in low- and middle-income countries since FCTC enactment [
7,
8].
Most countries have addressed all four WHO “best buy” interventions, although not necessarily to the extent the FCTC recommends. Countries have been delayed by internal political challenges, conflicts of interest among leadership, tobacco industry interference, and limited resources. This is similar to other reports of progress among low- and middle-income countries that have struggled with implementing “best buy” interventions, especially related to tobacco [
4,
5,
29].
Overall, the WHO FCTC has been enormously useful in reducing tobacco use and its health effects. Despite significant tobacco industry opposition, it remains the only international health treaty and has demonstrated success in reducing NCDs internationally. It is highly advisable to continue to improve both science and practice on how best to implement country-level implementation of international health treaties. Recommendations include: (a) how to best implement multi-sectoral action to ensure relevant stakeholders are included and their needs considered, (b) how politicians and civil service organizations can address tobacco industry engagement and interference, (c) how to address within-country conflicts of interest such as balancing needs related to tobacco’s benefits for farmers, tax revenues, and public health;, and (d) how to expand the reach of international health organizations to implement more treaties for improving global health.