Political economy of tobacco control in low-income and middle-income countries: lessons from Thailand and Zimbabwe
Global Analysis Project Team¹

Crucial to the success of the proposed Framework Convention on Tobacco Control will be an understanding of the political and economic context for tobacco control policies, particularly in low-income and middle-income countries. Policy studies in Thailand and Zimbabwe employed the analytical perspective of political economy and a research strategy that used political mapping, a technique for characterizing and evaluating the political environment surrounding a policy issue, and stakeholder analysis, which seeks to identify key actors and to determine their capacity to shape policy outcomes. These policy studies clearly revealed how tobacco control in low-income and middle-income countries is also being shaped by developments in the global and regional political economy. Hence efforts to strengthen national control policies need to be set within the context of globalization and the international context. Besides the transnational tobacco companies, international tobacco groups and foreign governments, international agencies and nongovernmental organizations are also playing influential roles. It cannot be assumed, therefore, that the tobacco control strategies being implemented in industrialized countries will be just as effective and appropriate when implemented in developing countries. There is an urgent need to expand the number of such tobacco policy studies, particularly in low-income and middle-income countries. Comprehensive guidelines for tobacco policy analysis and research are required to support this process, as is a broader international strategy to coordinate further tobacco policy research studies at country, regional and global levels.

Keywords: tobacco industry, legislation; public policy; politics; economics; commerce; Thailand; Zimbabwe.

Policy research for the Tobacco Free Initiative

An intergovernmental orking group, involving more than 100 WHO Member States, met in October 1999 and March 2000 to prepare proposed draft elements of the Framework Convention on Tobacco Control and to submit a report to the 53rd World Health Assembly. Formal negotiations are scheduled to begin with the convening ofthe first meeting ofthe Intergovernmental Negotiating Body by Dr Gro Harlem Brundtland, the Director-General of the World Health Organization (1). Crucial to the success of the Framework Convention on Tobacco Control will be an understanding ofthe policy environments for tobacco control policies, particularly in low-income and middle-income countries.

While extensive scientific evidence exists on the tobacco epidemic, international traffic in tobacco is increasing rapidly (2) and anti-tobacco litigation is spreading to more countries (3). However, recently policy research in support ofthe Framework Convention on Tobacco Control has also received a higher priority (4). Despite these developments, a lack of understanding remains on the policy environments within which tobacco control policies are being introduced and implemented. This deficiency is particularly pronounced in low-income and middle-income countries, where the global epidemic of tobacco smoking is expected to impact hardest and control policies face the greatest political challenge (5).

Since the proposed Framework Convention on Tobacco Control aims to provide legal, scientific and moral impetus at the global level in support of country efforts to control tobacco, the World Health Organization’s Tobacco Free Initiative commissioned the development ofguidelines for supporting such policy analyses. The project began with a recognition of the highly political nature ofthe tobacco issue and the complex vested interests concerned with tobacco control policies. Although the configuration of actors and their interests will be unique to individual countries, the global dimensions of the tobacco sector have clear implications for national control strategies. Using the analytical perspective of political economy, country case studies were carried out oftobacco control policies in Thailand (6) and Zimbabwe (7) to explore the responses of stakeholders across the three major areas of tobacco control policy, namely tobacco production, regulation of consumption, and health promotion activities. This paper reports on the lessons learned and the implications for similar country situations.

Studying the political economy of tobacco control

The adoption of political economy as the conceptual framework for the project reflected an acceptance of the basic proposition that politics and economics are inseparable, and recognition that global and regional pressures can condition the policy environment at the national level. Political economy provides an appropriate approach within which to study the wide variety of actors involved in tobacco control policies and to analyse their varied interests (8). During the 1980s, idespread economic changes and the adoption ofeconomic structural adjustment policies led to the application of political economy and public choice approaches to understanding policy reforms (9 –12). More recently political – economic models have been constructed for policy reform in developing countries (13 –15), which argue that political economy theory combined with empirical studies can help to predict which actors will be active and influential around specific policy issues. This research was supported by developments in the application of political economy to health policy (16, 17) and tobacco (5, 18). The research also viewed policy-making, not simply as the outcome ofstructural context (e.g. global economy) and contexts, but also of agency — the way in which individuals and institutions may act to influence policy agendas, decisions and outcomes.

The configuration of actors with respect to tobacco control and to more specific policy issues constituted the ‘micro-environments’ policy for analysing the ‘balance of forces’ for and against tobacco control, using methods related to political mapping and stakeholder analysis (19). Political mapping is ‘‘a technique used to characterize and evaluate the political environment surrounding a policy issue’’ (20), while stakeholder analysis seeks to identify actors with a key interest in an issue and to determine their capacity to shape outcomes (21). While the primary focus was necessarily on the national level, relevant features of the global political economy, the broader policy environment, and the actions of influential external actors and agents were also investigated. Information was mainly obtained from primary documents and interviews of key informants, supplemented by material from the archives ofindustry documents disclosed following a 1998 decision by the Court ofthe State of Minnesota in the United States.

Global political economy of tobacco control

The policy environments for tobacco control in both Thailand and Zimbabwe are clearly being shaped by developments in the global political economy, which means that efforts to strengthen national control policies need to be set within the context of globalization. The extent to which the contemporary international economy is dominated by the preeminence of liberal perspectives has serious consequences for tobacco control. For instance, Zimbabwe’s adoption of a programme of economic structural adjustment has heightened reliance upon tobacco production and exports for earning foreign currency, while the International Monetary Fund’s enthusiasm for the privatization of state enterprises has brought into question the future ownership of the Thailand Tobacco Monopoly.

Reductions in trade tariffs associated with economic regionalization are increasingly shaping the manufacture and trade in cigarettes in South-East Asia and in Southern Africa. For instance, there has already been penetration of the Thai cigarette market by the transnational tobacco companies which, assisted by the Association of South East Asian Nations (ASEAN) tax agreements, have shifted production to Malaysia to benefit from preferential tariffs and reduced transport costs. In Africa, the Southern African Development Community is already in operation and, given the prominence of the South African economy, considerable opportunities exist for the relocation of manufacturing plants and the preferential marketing of cigarettes across adjacent countries.

Globalization of the tobacco industry itself has clear impacts at the national level. For instance, Thailand constitutes a key market for the transnational tobacco companies in their re-orientation away from traditional markets in North America and Western Europe. While Zimbabwe is a valuable source of high quality tobacco, it also remains highly vulnerable to changes in international production patterns and price fluctuations. The International Tobacco Growers’ Association has served as a vehicle by which domestic producer interests have been linked with those of the transnational tobacco companies in resisting progress towards tobacco control. The motivation in forming the International Tobacco Growers’ Association was to create a cohesive international organization that could actively defend the interests of the industry (22). In 1993, the then Chairman of the Tobacco Research Board of Zimbabwe secured the willingness of the International Tobacco Growers’ Association, of which he was a former Chairman, to serve as ‘‘front line troops’’ in collecting and collating scientific data to be used in aggressively countering anti-smoking lobbies (23). Zimbabwe’s tobacco industry has also contributed to broader efforts to resist and distort the World Health Organization’s tobacco control agenda. Inter-office correspondence in the United States from Philip Morris regarding lobbying in the run up to the World Health Assembly in 1986 noted that ‘‘excellent argumentation has been produced by the Tobacco Industry Council in Zimbabwe’’ (24).

The domestic–foreign frontier is being blurred by a range ofglobal actors (25). Foreign governments, transnational companies, international agencies and nongovernmental organizations can be very influential, as shown by the actions of the United States in threatening trade sanctions in support of transnational tobacco company attempts to secure entry into Thailand’s previously closed cigarette market. The US Departments of State and Treasury supported the US Trade Representative in taking the Thai case to the General Agreement on Tariffs and Trade (GATT), while the US delegation to the arbitration panel insisted that this dispute was simply a trade issue and objected to Thailand’s attempts to involve the World Health Organization. The arbitrating role of GATT in this dispute is a dramatic example of the impact of international organizations on tobacco control at the national level. Although the GATT ruling insisted upon the equal treatment of domestic and foreign cigarette manufacturers, it also upheld Thailand’s right to impose comprehensive tobacco control measures (26).

This illustrates that globalization and the interventions ofexternal actors should not necessarily be viewed as inimical to the protection of public health.Thailand’s case was also actively supported by international nongovernmental organizations and the scientific stand taken by the World Health Organization, while subsequent tobacco control legislation was deliberately modelled on the example established by Canada. In Zimbabwe, the Framework Convention on Tobacco Control initiative has already resulted in the formation of a National Task Force mandated to develop a national framework for tobacco control, while downward pressure on international tobacco prices constitutes the most powerful incentive towards agricultural diversification away from the growing of tobacco.

Tobacco control in Thailand and Zimbabwe: achievements and prospects

The two case studies clearly demonstrated the value of political mapping and stakeholder analysis in understanding the diversity of tobacco control measures at national level. Thailand’s passage during 1992 ofextensive legislation in the Tobacco Products Control Act and the Non-Smokers Health Protection Act included the prohibition of all forms of cigarette advertising, provisions for ingredient disclosure and the use of rotating health warnings occupying 25% of package space. A satisfactory explanation of their implementation requires recognition of the unique circumstances of the regime installed following the military coup of 1991. The suspension of Thailand’s established political system restricted the ability of tobacco interests to disrupt the legislative process, while the Deputy Health Minister was one of the founders of Thai ASH, an active nongovernmental organization advocating greater tobacco control. Crucial importance is also attached to the context of the dispute with the USA, with the passage of control legislation representing a face-saving measure for the opening of Thailand’s cigarette market.

The circumstances in which the Health Promotion Bill is currently being debated do not seem so propitious. The Health Promotion Bill proposes the establishment ofa health promotion fund to be financed by the imposition of a 2% levy on producers and importers ofalcohol and tobacco products. Amid pressure for the privatization of the Thailand Tobacco Monopoly and in the context of striking recent increases in the market share of transnational tobacco companies, the Health Promotion Bill faces formidable opposition. The scale of measures already implemented and the strength of the anti-tobacco movement do, however, constitute powerful resources for advancing tobacco control, particularly in combination with the support of the Ministry of Finance. There have been changes in US foreign policy with reference to tobacco. The US Congress has attempted to circumscribe the role of the US Trade Representative in promoting tobacco industry interests abroad with the Doggett amendment (27), which seeks to prevent government officials overseas from promoting tobacco interests or opposing control legislation. This might be cited as a favourable development in an international context, though the significance and implementation of this change has been questioned (28).

By contrast, Zimbabwe has achieved only limited regulation, such as a voluntary health warning and the prohibition ofsales to children without parental consent, although progress is suggested with the current existence ofdraft legislation. This progress has been heavily dependent on the personal enthusiasm ofthe longstanding Minister of Health and Child Welfare, particularly as the organization and influence of Thailand’s nongovernmental health organizations has no real counterpart in Zimbabwe. The preeminence accorded to tobacco production in Zimbabwe has been viewed as negating the possibility of implementing tobacco control measures, yet this need not be the case. While any apparent threat to producer interests would probably constitute political suicide, the industry’s overriding focus on exports leaves substantial scope for action on tobacco consumption. However, the magnitude of other public health issues, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), malaria and road traffic accidents, severely constrains the resources that can be devoted to tobacco control.

Lessons for tobacco policy research

The study generated useful lessons for the conduct of such policy research studies and clarified some priorities for future research. In addition, it became clear that a broader research strategy is needed for the next generation of tobacco policy studies.

The Global Analysis Project confirmed that: political economy is a robust conceptual framework for use in such studies; focusing on the national context and national–international interface was highly appropriate; national documentation and the printed media can provide important information on the national policy-making process; valuable and meaningful policy conclusions can be obtained from semi-structured interviews with key informants at the national level; useful and additional perspectives can be obtained through informal interviews with key policy actors at the sub-national level; and industry documents disclosed as a result oflitigation constitute an invaluable resource for policy analysis.

These two case studies also offer several lessons for understanding and developing national policies on global tobacco control. In terms of policy research, it is clear that expertise from both public health and social science is needed to analyse the complex political and economic forces at play. However, such qualitative policy research also strongly depends on the presence of highly skilled social scientists, preferably with relevant international experience, as well as expert knowledge of the national context and the various actors in the tobacco sector. While a multidisciplinary team needs to operate within a shared conceptual and analytical framework, this must be sufficiently flexible to accommodate variations in skills and perspectives, as well as across national contexts.

Such multidisciplinary research also needs a relatively neutral base in which to conduct such work, such as a respected and independent research institute or university. For such studies to be carried out in low-income and middle-income countries that may lack the necessary expertise, technical support for capacity strengthening may be needed to attain the required level of expertise and skills in each country.

Priorities for future country policy studies

In terms of applying research to policy development, the project demonstrated the direct importance of an in-depth understanding of the national policy environments into which global health strategies may be introduced. It also shows that the implementation of the Framework Convention on Tobacco Control will depend as much on getting the politics right as on utilizing our extensive scientific knowledge.

A conclusion from these studies is that it cannot be assumed that the tobacco control policies being implemented in economically more developed countries will be just as effective and appropriate in the middle-income and low-income countries, where policy environments are different and the effects of globalization are becoming very apparent. More national tobacco policy research studies using analyses provided by political economy and international perspectives, and based on political mapping and stakeholder analysis, could be a very powerful way forward.

In conclusion, two urgent priorities exist if the future momentum for tobacco policy research is to be maintained and the Framework Convention on Tobacco Control is to be successfully implemented by WHO Member States. Firstly, a comprehensive set of guidelines for tobacco policy analysis and research is a necessity, if policy-makers are to become more aware of the forces for and against greater tobacco control in their countries. These guidelines should utilize the approach of political economy and be made widely available for use by national researchers with limited international support. Secondly, there is also an urgent need for a new and broader international strategy that supports and coordinates tobacco policy research at country, regional and global levels, particularly for the benefit of middle-income and low-income countries. If the Framework Convention on Tobacco Control is to be successful, this strategy also needs to encourage international organizations, donor agencies and health foundations to develop a common policy research agenda, with much greater priority being given to tobacco control policies in the developing world.§

Acknowledgements

The research team is very pleased to acknowledge the support and funding received from the Tobacco Free Initiative of the World Health Organization, Geneva, and we also warmly acknowledge the personal support given by Derek Yach, Douglas Bettcher and Roberta Walburn. The research teams interviewed many different officials, both governmental and nongovernmental, in Thailand, Zimbabwe and the United Kingdom who willingly gave their time, comments and views. We acknowledge the debt that this study owes to them. However, the views expressed in this document are the sole responsibility of the authors and do not necessarily represent those of the World Health Organization or the governments of Thailand or Zimbabwe.

Résumé

Economie politique de la lutte antitabac dans les pays à faible revenu et à revenu moyen : le cas de la Thaïlande et du Zimbabwe

La réussite du projet de convention-cadre pour la lutte antitabac dépendra essentiellement d’une bonne compréhension de l’environnement dans lequel s’inscri-ront les politiques de lutte antitabac, en particulier dans les pays à faible revenu et à revenu moyen. Dans une étude entreprise à la demande de l’initiative Pour un monde sans tabac de l’Organisation mondiale de la Santéen vue d’élaborer des lignes directrices pour appuyer les analyses de politiques, des études de cas ont étéentreprises en Thaïlande et au Zimbabwe. Le but était d’étudier la réaction des différents intervenants dans les trois principaux domaines visés par la politique anti-tabac, à savoir la production de tabac, la réglementation de la consommation et les activités de promotion de la santé. Si l’on a choisi comme cadre conceptuel pour ces études l’économie politique, c’est parce que l’on sait que politique et économie sont indissociables et que l’environnement politique national n’échappe pas aux pressions régionales et mondiales. Il s’agit donc d’un cadre appropriépour déterminer quels sont les divers acteurs qui infléchissent les politiques de lutte antitabac ou en subissent les effets et étudier la complexitédes intérêts en cause. L’étude s’est appuyée sur les progrès faits dans l’application de l’économie politique aux pays en développement, à la politique sanitaire et au tabagisme. A partir d’une stratégie de recherche fondée sur les techniques de cartographie politique et d’analyse des intervenants, on a pu définir précisément les caractéristiques des principaux intervenants, qu’ils soutiennent certaines mesures de lutte antitabac ou y soient opposés.
Ces caractéristiques ont montréclairement comment, dans ces pays, la lutte antitabac est également conditionnée par l’évolution de l’économie politique mondiale. Aussi les efforts destinés à renforcer les politiques nationales de lutte doiventils s’inscrire dans le contexte de la mondialisation et de l’économie internationale. Les limites entre économie intérieure et économie internationale étant de plus en plus confuses, on s’aperçoit que les sociétés transnationales productrices de tabac, les grands groupes internationaux producteurs de tabac, les gouvernements étrangers, les organismes internationaux et les organisations non gouvernementales exercent tous une influence. On considère souvent que ces interventions nuisent à la lutte antitabac au niveau national, mais le cas de la Thaïlande et du Zimbabwe permet de mettre en évidence à la fois les obstacles à surmonter et les possibilités d’action. Si l’ouverture forcée du marchéde la cigarette thaïlandais à la concurrence étrangère a récemment entraîné une hausse spectaculaire de la part de marché des sociétés transnationales, la décision de l’Accord général sur les Tarifs douaniers et le Commerce (GATT) a aussi favorisél’adoption d’une importante législation antitabac en Thaïlande grâce à l’action dynamique des associations de promotion de la santé. Quant au Zimbabwe, ce n’est pas parce que le pays est éminemment tributaire de la production de tabac pour son économie que toute perspective de faire progresser les mesures de lutte antitabac encore limitées en vigueur dans le pays doit être exclue, car une analyse détaillée des préoccupations majeures des principaux intervenants laisse supposer qu’une action en faveur de la réduction de la consommation de tabac ne serait pas forcément vouée à l’échec.
Une évaluation des réalisations et des perspectives de la lutte antitabac dans les pays à faible revenu ou à revenu moyen exige donc une analyse détaillée des positions et des stratégies des acteurs aussi bien nationaux que transnationaux. Les deux études de cas décrites ici montrent l’utilitéde la cartographie politique et de l’analyse des intervenants pour mieux comprendre la diversitédes mesures qu’appelle la lutte selon les Etats. En ce qui concerne l’élaboration de la convention-cadre pour la lutte antitabac, on ne peut pas partir du principe que les stratégies de lutte antitabac mises en oeuvre dans les pays industrialisés seront aussi efficaces et adaptées dans les pays en développement. Ces études montrent que si l’on veut que la convention-cadre aboutisse, il faut d’urgence multiplier le nombre d’études sur les politiques antitabac réalisées en particulier dans les pays à faible revenu et à revenu moyen. Il convient par ailleurs d’élaborer des principes directeurs pour l’étude et l’analyse des politiques antitabac. Il conviendrait également d’élaborer une stratégie internationale plus large afin de coordonner les nouvelles études sur la politique antitabac aux niveaux national, régional et mondial.

Resumen

Economía política de la lucha antitabáquica en los países de ingresos bajos y medios: lecciones de Tailandia y Zimbabwe

El éxito del Convenio Marco para la Lucha Antitabáquica dependeráde forma crucial del conocimiento que se tenga de los marcos normativos de las políticas de lucha antitabáquica, en particular en los países de ingresos bajos y de ingresos medios. En el marco de investigaciones encargadas por la Iniciativa «Liberarse del tabaco» de la Organización Mundial de la Salud para formular directrices en apoyo de los análisis de políticas, se llevaron a cabo estudios de casos en Tailandia y Zimbabwe a fin de analizar las respuestas de los interesados directos en los tres sectores principales de la política de lucha antitabáquica, a saber, la producciónde tabaco, la reglamentación del consumo y las actividades de promoción de la salud. Se adoptóla economía política como marco conceptual de esos estudios, por cuanto se consideróque la política y la economía son inseparables y que los marcos normativos nacionales están condi-cionados por presiones mundiales y regionales. Esto proporciona un contexto apropiado para analizar la amplia variedad de actores que influyen en las políticas de lucha antitabáquica y se ven afectados por ellas, así como la complejidad de sus intereses. La investigaciónse vio respaldada por diversas novedades en materia de aplicación de la economía política a los países en desarrollo, las políticas de salud y el tabaco. Empleando una estrategia de investigación basada en técnicas de cartografía política y de análisis de los interesados directos, se logróidentificar las configuraciones particu-lares de actores clave en lo que respecta al apoyo o rechazo a aspectos concretos de la lucha antitabáquica.
Esas configuraciones revelaron claramente que en esos países la lucha antitabáquica también se ve conformada por la evolución de la economía política mundial. Así pues, los esfuerzos desplegados para fortalecer las políticas nacionales de lucha deben establecerse en el contexto de la mundialización y de la economía internacional. A medida que se desdibujan las fronteras entre lo nacional y lo internacional, es posible discernir las influencias más determinantes dentro del espectro de empresas tabacaleras trans-nacionales, grupos internacionales favorables al tabaco y gobiernos extranjeros, organismos internacionales y organizaciones no gubernamentales. Se considera a menudo que esas intervenciones socavan las perspec-tivas de la lucha antitabáquica a nivel nacional, pero tanto en Tailandia como en Zimbabwe se puede distinguir un modelo complejo de oportunidades y obstáculos. Aunque la obligada apertura del mercado de cigarrillos de Tailandia a la competencia extranjera ha provocado recientemente un sorprendente aumento de la cuota de mercado de las empresas tabacaleras transnacionales, en la misma decisión del Acuerdo General sobre Aranceles Aduaneros y Comercio (GATT) se imprimióun gran impulso a los esfuerzos de los activistas de la salud al asegurarse la aprobación de una extensa legislación de lucha antitabáquica para el país. La gran dependencia de Zimbabwe de la producción de tabaco no debería ser considerada como un impedimento para impulsar las limitadas medidas de control ya adoptadas, pues un análisis detenido de las inquietudes más importantes de actores clave lleva a pensar que hay margen para actuar y reducir el consumo del tabaco.
Para evaluar los logros y las perspectivas de la lucha antitabáquica en los países de ingresos bajos y medios, por consiguiente, se requiere un análisis detallado de las posiciones y las estrategias de los actores tanto nacionales como transnacionales. Los dos estudios de casos aquí descritos demuestran la utilidad de la cartografía política y del análisis de los interesados directos con miras a comprender la diversidad de las medidas de control entre unos Estados y otros. En el contexto de la elaboración de un Convenio Marco para la Lucha Antitabáquica, no puede darse por sentado que las estrategias de lucha antitabáquica que se están aplicando en los países industrializados serán igual de eficaces e idóneas cuando se apliquen en los países en desarrollo. Estos estudios demuestran que, para que el Convenio Marco para la Lucha Antitabáquica sea un éxito, es necesario y urgente realizar más estudios de esa naturaleza sobre las políticas antitabáquicas, en particular en los países de ingresos bajos y medios. En apoyo de este proceso, se necesitan directrices detalladas para el análisis e investigación de las políticas relacionadas con el tabaco. Se requiere también una estrategia internacional más general para coordinar los futuros estudios de investigación de las políticas antitabáquicas a nivel nacional, regional y mundial.

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¹ Sombat Chantornvong (Thammasat University, Bangkok, Thailand); Jeff Collin (London School of Hygiene and Tropical Medicine, England); Richard Dodgson (London School of Hygiene and Tropical Medicine, England); Kelley Lee (London School of Hygiene and Tropical Medicine, England); Duncan McCargo (University of Leeds, England); David Seddon (University of East Anglia, Norwich, England; Patrick Vaughan (London School of Hygiene and Tropical Medicine, England); Godfrey Woelk (University of Zimbabwe Medical School, Harare, Zimbabwe). Correspondence should be sent to Professor J. Patrick Vaughan at the following address: Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, England (email: patrick.vaughan@lshtm.ac.uk).

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