Abstract

This research aimed to analyze the National Committee for the Implementation of the Framework Convention on Tobacco Control (CONICQ). The study covered the period from 2003 to 2015 and built on the referential analysis of public policies, considering structure and political process and Committee’s agenda and performing capacity. Methodological strategies were documentary analysis, including Committee’s minutes of meetings, direct observation of events and interviews with key stakeholders. The regular functioning and gradual expansion of the Committee was observed in the period, permeated by technical and political aspects that influence its structuring and the establishment of the agenda. Conflicts have been identified among CONICQ members and between these and external stakeholders, especially from the clashing opinions on economic and health-related viewpoints. Its capacity for action was limited by internal (from some government agencies) and external (from organizations linked to the tobacco industry and tobacco growers) resistance. CONICQ is a strategic instance to the Brazilian tobacco control policy. However, its activity as an intersectoral coordination mechanism is complex, given the different interests, stances and levels of engagement of agencies involved in tobacco control.

Tobacco; Health management; Public health policy

Introduction

Tobacco use is the leading cause of premature mortality in the world, accounting for six million deaths annually¹1. Khazaei S, Mohammadian-Hafshejani A, Ahmadi Pishkuhi M, Salehiniya H. Proportion of Mortality Attributable to Tobacco Worldwide. Iran J Public Health 2016; 45(3):399-400.. The power of scientific evidence, the role of various leaderships and the imposed limits on transnational tobacco companies have been fundamental for its reduction²2. Wipfli H, Samet JM. One Hundred Years in the Making: The Global Tobacco Epidemic. Annu Rev Public Health 2016; 37(1):149-166..

The Framework Convention on Tobacco Control (FCTC)³3. World Health Organization (WHO). WHO Framework Convention on Tobacco Control. Geneva: WHO; 2003., in force worldwide since 2005, is the first negotiated legislation involving the World Health Organization (WHO). Its success depends on countries’ ability to ensure the implementation of effective tobacco control polices, including the incentive of policy coordination mechanisms⁴4. Wipfli H, Stillman F, Tamplin S, Costa e Silva VL, Yach D, Samet J. Achieving the Framework Convention on Tobacco Control’s potential by investing in national capacity. Tob Control 2004; 13(4):433-437..

Brazil is an international reference in tobacco control and one of the leaders in FCTC’s negotiations⁵5. Lee K, Chagas LC, Novotny TE. Brazil and the Framework Convention on Tobacco Control: Global Health Diplomacy as Soft Power. PLoS Med [Internet]. abril de 2010 [acessado 2014 Ago 1]; 7(4). Disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2857639/
http://www.ncbi.nlm.nih.gov/pmc/articles... . It is a model of interministerial management responsible for the coordination of the National Tobacco Control Policy (PNCT). Established in 2003, the National Committee for the Implementation of the Framework Convention on Tobacco Control (CONICQ) seeks to fulfill its obligations under the FCTC and is responsible for representing the Brazilian government in venues promoted by the Convention, such as the Conferences of the Parties (COP)⁶6. Brasil. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto s/n, de 1o de agosto de 2003. Diário Oficial da União 2003; 1 ago.. Together with other stakeholders such as researchers, policymakers and civil society, CONICQ has been instrumental in advancing tobacco control in the country⁷7. Costa e Silva VL, Pantani D, Andreis M, Sparks R, Pinsky I. Bridging the gap between science and public health: Taking advantage of tobacco control experience in Brazil to inform policies to counter risk factors for non-communicable diseases. Addiction 2013; 108(8):1360-1366..

Composed of several government agencies, CONICQ is the main intersectoral coordination body of the PNCT. Intersectoriality has been advocated in the formulation of health policies, given the multifaceted character of the health-disease process⁸8. Akerman M, Franco de Sá R, Moyses S, Rezende R, Rocha D, Akerman M, Rezende R, Rocha D. Intersectoriality? IntersectorialitieS! Cien Saude Colet 2014; 19(11):4291-4300.. However, the articulation of policies that comprise economic and social realms, involving several groups, is permeated by conflicts⁹9. Rezende M, Baptista TWF, Amâncio Filho A, Rezende M, Baptista TW F, Amâncio Filho A. The legacy of the construction of the brazilian social protection system for intersectoriality. Trab Educ E Saúde 2015; 13(2):301-322.. Tobacco control policy is complex and with diverse action fronts and, thus, requires the involvement and articulation of several sectors. Studying CONICQ’s performance can contribute to understanding the challenges of intersectoral policy coordination.

This paper seeks to analyze the CONICQ, considering its structure, political process, agenda and capacity for action.

Methodology

The study was based on the public policy analysis framework, with emphasis on the political process, which encompasses power relations between stakeholders in the political arenas, as well as on the Committee’s agenda¹⁰10. Buse K, Mays N, Walt G. Making health policy. 2nd ed. Maidenhead: Open Univ. Press; 2012. (Understanding public health).. Historical institutionalism contributions were also considered. The Committee was valued as an instance of shared definition of rules and agenda, which may favor institutional politics towards greater solidity and stability of its trajectory over time, with positive feedback elements¹¹11. Pierson P. Politics in Time: History, Institutions, and Social Analysis. Princeton: Princeton University Press; 2004..

Two lines of analysis were defined. The first, Structure and Political Process, consisted in describing the formation, composition and structure of the CONICQ and in analyzing the participation, stances and relationships among members of the Committee and with external stakeholders. The second line, Agenda and Capacity for Action, built on Kingdon’s agenda concept¹²12. Kingdon JW. Agendas, Alternatives, and Public Policies. 2nd ed. New York: HarperCollins College Publishers; 2010. [Longman Classics in Political Science]., referring to the set of themes that mobilized the attention of government agents (in this case, members of the Committee) – and involved the analysis of the content of debates and the Committee’s ability to implement its proposals.

The methodological strategies implemented were documentary analysis of laws, norms and publications on tobacco control made available on the Internet. Also analyzed were the minutes of 36 CONICQ meetings held between 2003 and 2014, requested through the Citizen Information Service Electronic System of the Federal Government¹³13. e-SIC - Sistema Eletrônico do Serviço de Informação ao Cidadão [Internet]. [acessado 2017 Maio 31]. Disponível em: https://esic.cgu.gov.br/sistema/site/index.html
https://esic.cgu.gov.br/sistema/site/ind... .

We should add the direct observation of the First Open Meeting of CONICQ and the 10-year Workshop of the WHO Framework Convention on Tobacco Control in Brazil, both held in Brasilia in 2015. In the same year, 20 semi-structured interviews were conducted with PNCT stakeholders: 14 leaders and federal officers whose agencies are part of the CONICQ (identified as DTF 1-14); three representatives of civil society organizations supporting the PNCT (OSC 1-3); two federal deputies (Leg. 1-2) and one representative of the FCTC Secretariat at WHO (Sec. CQCT). E-mail responses of a representative from a civil society organization linked to the tobacco industry (OSCI) were also analyzed. We used the OpenLogos¹⁴14. OpenLogos [Internet]. [acessado 2017 Maio 31]. Disponível em: http://openlogos.sourceforge.net/
http://openlogos.sourceforge.net/... managing tool to support the analysis.

The Research Ethics Committee of the institution of origin approved the research project.

Results

Structure and political process

Between 1999 and 2003, Brazil’s participation in international negotiations aimed at the elaboration of the FCTC was coordinated by the National Committee for Tobacco Use Control (CNCT). This Committee consisted of nine ministries, with important action of the Ministry of Health, since the minister was the president and the National Cancer Institute (INCA) the Executive Secretariat¹⁵15. Brasil. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 3.136, de 13 de agosto de 1999. Diário Oficial da União 1999; 13 ago..

In 2003, with the establishment of the FCTC, the CNCT was replaced by the National Committee for the Implementation of the FCTC (CONICQ), and agencies that were part of the previous committee were kept and others were incorporated (Figure 1). According to respondents, the diverse aspects involved in tobacco control required an interministerial structure, gradually reformulated from the identification of stakeholders that could contribute to the implementation of the FCTC in the country.

It is worth highlighting the relevance of INCA’s performance in CONICQ. The status of the Executive Secretariat and the Vice-Presidency conferred on the Institute is related to its importance in the control of cancer in the country and to the historical participation of some of the Institute’s officials in the tobacco control policy and in the establishment of the FCTC itself.

We underscore the establishment of the National Health Surveillance Agency (ANVISA) as a specific member of the Committee as from 2012. Respondents mentioned that the attribution of a proper seat for ANVISA was related to its relevant role in the regulation of tobacco-derived products.

CONICQ’s competencies were initially included in the Decree of its foundation⁶6. Brasil. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto s/n, de 1o de agosto de 2003. Diário Oficial da União 2003; 1 ago.. In 2007, CONICQ’s meeting minutes express concerns about members’ responsibilities and the Committee’s operating dynamics, leading to the formulation of the Internal Rules in 2011.¹⁶16. Brasil. Ministério da Saúde (MS). Portaria no 1.083, de 12 de maio de 2011. Aprova o Regimento Interno da Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco (CONICQ). Diário Oficial da União 2011; 12 maio. Rules further specified the responsibilities of CONICQ’s Executive Secretariat, such as organization of the Committee’s activities, facilitating coordination between agencies involved and monitoring of the implementation of the FCTC in the country.

The competencies of the president, vice-president and other members were also specified, with emphasis on the provision of collaboration of all members in the articulation of intersectoral plans and actions. Rules also provide for the dynamics of meetings, hearings, working groups and communication mechanisms.

From the minutes, we identified initiatives by CONICQ’s Executive Secretariat to organize seminars, groups and workshops to enable compliance with the FCTC. The preparation of annual work plans and the adoption of tools to follow up on the implementation of actions, such as the Management and Progress Report¹⁷17. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Comissão Nacional para Implementação da Convenção - Quadro para controle do Tabaco. Política Nacional de controle do tabaco: relatório de gestão e progresso 2011-2012. Rio de Janeiro: INCA; 2014. were strategies for organizing activities, setting the agenda and supporting the completion of periodic progress reports on the implementation of measures defined in the FCTC, which are requested by the WHO FCTC Secretariat prior to each Conference of the Parties.

We noted the adoption of several internal strategies of communication and dissemination of actions to society. As of 2010, a Working Group (WG) was established and consisted of ministerial communications advisors to strengthen this process. In 2011, the Observatory of the National Tobacco Control Policy was established¹⁸18. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Observatório da Política Nacional de Controle do Tabaco. Home. [Internet]. [acessado 2017 Maio 31]. Disponível em: http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home
http://www2.inca.gov.br/wps/wcm/connect/... and it was agreed that members would contribute with their content.

Some strategies to foster member participation are highlighted. According to minutes, in 2006, a meeting rotation system was proposed. However, of the 36 CONICQ meetings, only six meetings did not take place at the Ministry of Health’s premises in Brasilia (two meetings took place in the capital, namely, at the Ministry of Foreign Affairs (MRE), one at the Ministry of Agrarian Development (MDA) and one at the Oswaldo Cruz Foundation in Rio de Janeiro; two meetings were held at the INCA). In addition to rotation, in the same year, CONICQ’s Executive Secretariat also suggested establishing intra-ministerial committees to strengthen the implementation of the FCTC and shared the experience of the Intra-ministerial Committee in the Ministry of Health. However, according to reports of respondents and minutes’ records, this proposal gradually lost its strength.

The involvement of agencies with the Committee is evidenced by the participation of members in the meetings. It is possible to verify the participation of several instances of the Ministry of Health, with emphasis on the International Health Affairs Advisory Office (AISA), ANVISA, INCA and the Secretariat of Health Surveillance (SVS). However, not all of Ministry of Health’s agencies had a permanent seat in the CONICQ. Some were especially invited to the meetings or participated at certain stages to discuss specific strategies under their responsibility. In addition to the Ministry of Health, MRE and MDA were the most frequent attendees (Figure 2). The minutes evidenced collective efforts to seek out less-frequent attending agencies at the Committee’s meetings.

Regarding the hierarchical level of positions held by participants of CONICQ’s meetings, the minutes showed that, in general, the federal agencies were represented in the meetings of the Committee by mid-level officers – directors and coordinators – or by advisors of ministers and secretaries. That is, most of the representatives are not people with high decision-making power positions, but with a technical-political profile, who coordinate tobacco control-related actions in their agencies. Minutes also showed frequent changes of representatives of CONICQ’s agencies, despite the recommendation to avoid rotation of representatives. However, a single representative of INCA was registered in all 36 meetings analyzed (Table 1). The change of representatives and the inclusion of new agencies in the CONICQ were frequently discussed in the meetings.

Respondents affirm that the change of representatives of the agencies that are part of the CONICQ would be related in part to the changes of management in the ministries. However, one respondent of the CONICQ’s Executive Secretariat highlighted that this rotation was a challenge:

This part is hard to manage. That is why the secretariat’s role is crucial. We will hold bilateral meetings to support these people. We have this act of sitting depending on the stage of that person and the action that he/she coordinates... (DTF 12).

While CONICQ regulations do not provide for the inclusion of new members, it only proposes to articulate with other agencies and experts when appropriate⁶6. Brasil. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto s/n, de 1o de agosto de 2003. Diário Oficial da União 2003; 1 ago.,¹⁶16. Brasil. Ministério da Saúde (MS). Portaria no 1.083, de 12 de maio de 2011. Aprova o Regimento Interno da Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco (CONICQ). Diário Oficial da União 2011; 12 maio., the minutes of the meetings evidenced discussions about the inclusion of new agencies in the Committee. In addition to the discussion that involved the seven agencies included as of 2010 (Figure 1), the incorporation of other stakeholders (Ministry of Social Development, Ministry of Sports, Secretariat of Institutional Relations and civil society) was scheduled in the meetings. The request of ONGs for incorporation into CONICQ, such as health advocacy organizations and entities related to tobacco growers and the tobacco industry generated dilemmas:

... A Working Group was established to discuss the participation of civil society, because we want civil society working with us, but we want to do it in a way that does not open the way for industry’s infiltration... (DTF 12).

Strategies for articulation with civil society and external players were recorded in the minutes and interviews: hearings during Committee’s meetings, public hearings, seminars, open meetings, workshops and working groups.

The direct observation of the First Open Meeting of the CONICQ and the Workshop commemorating the 10 years of FCTC existence in 2015 allowed the visualization of this interaction. The first space was marked by a debate of representatives of the Ministry of Health, Ministry of Agrarian Development and civil society organizations that advocate public health and family agriculture with representatives of tobacco growers and the tobacco industry. FCTC’s commemorative event has been shown to be a space for dialogue and construction of a joint evaluation of the National Tobacco Control Policy by civil society, academia and subnational spheres. It is worth noting the leading role of CONICQ’s Executive Secretariat and the active participation of the Ministry of Health in these settings.

Legislative arenas have been widely used for dialogue among policy stakeholders, involving both public health advocacy groups and representatives of tobacco growers and the tobacco industry. Hosting events in the House of Representatives and the Senate and the follow-up to the discussions of the committees of these Houses was a strategy used by CONICQ to advance legislative demands, such as FCTC’s ratification process (2003-2005). It is also worth mentioning the Committee’s articulation with the Judiciary to reinforce the scientific evidence supporting the measures adopted by the FCTC, as the tobacco industry has begun to challenge certain actions, such as the prohibition of the use of additives in cigarettes.

Relationships with international organizations and other countries were also frequently addressed in the meetings. In addition to its articulation with the MERCOSUR countries, CONICQ participated in preparatory meetings for the Conferences of the Parties (COPs) and in international working groups to formulate guidelines for FCTC-specific themes. Brazil participated in all working groups defined in the COP, except in relation to Article 12 of the FCTC (Education, communication, training and public awareness) (Figure 3).

Conflicts of interest regarding the tobacco industry and other economic issues were also addressed. The tension generated during the fourth Conference of the Parties - COP4 (2010), during which a representative of the Ministry of Development, Industry and Foreign Trade (MDIC) had a contact with a tobacco company without the consent of the rest of the Brazilian delegation compromised the country’s fair participation in the Conference with regard to the interference of the tobacco industry in its stance.

Another example was the debate around the preparatory document for the Fifth Conference of the Parties - COP5 (2012), formulated by the International Working Group on Sustainable Alternatives to Tobacco Growing¹⁹19. Organização Mundial da Saúde (OMS). Economically sustainable alternatives to tobacco growing (in relation to Articles 17 and 18 of the WHO Framework Convention on Tobacco Control). Conference of the Parties to the WHO Framework Convention on Tobacco Control. Fifth session. 2012. [Internet]. [acessado 2017 Abr 13]. Disponível em: http://apps.who.int/gb/fctc/PDF/cop5/FCTC_COP5_10-en.pdf
http://apps.who.int/gb/fctc/PDF/cop5/FCT... . The reduced planted area of tobacco proposed by the document generated disagreement among the members of CONICQ, expressed mainly by the representative of the Ministry of Agriculture, Livestock and Supply – MAPA. Civil society organizations linked to tobacco growers and the tobacco industry also opposed the document. Faced with the deadlock, the efforts by CONICQ’s Executive Secretariat and the Ministry of Foreign Affairs to clarify that the Committee would not agree with the proposal stood out.

Conflicts of interest involving the tobacco industry were often debated. At the first CONICQ meetings in 2003, members were asked to make a statement that personal interests would not conflict with the work of the Committee. Among conflicts related to this requirement is a statement by a MAPA representative, who affirmed that the signing of the declaration by some agencies – such as MAPA itself and MDIC – was unfeasible due to its relationships with the tobacco industry. In addition to the determination for CONICQ members to sign the declaration of conflict of interest, Ethical Guidelines²⁰20. Brasil. Ministério da Saúde (MS). Portaria no 713, de 17 de abril de 2012. Torna pública a Resolução no 1, de 15 de dezembro de 2011, que estabelece as Diretrizes Éticas aplicáveis aos membros da Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco e de seus Protocolos (CONICQ), na forma do anexo. Diário Oficial da União 2012; 17 abr. that guided the practices of members to ensure impartiality in the work developed were also formulated:

... some sectors of CONICQ itself must have interfaces with the industry. In addition, we had to figure out how that could be done. Setting limits, how far we can go and where we should not venture, as officers addressing the Tobacco Control Policy, to avoid conflicts of interest. CONICQ’s Executive Secretariat, together with the AGU, developed the guidelines to lead CONICQ’s members in their interface (DTF 12).

Some examples of situations of potential conflict of interest identified in the minutes of the CONICQ meetings and mentioned by respondents were Federal Police partnerships with the tobacco industry for actions to combat illegal trade; and the Ministry of Labor and Employment’s (MTE) interaction with unions in the tobacco growing sector and the tobacco industry.

Tensions related to the Sectoral Chamber of MAPA’s Tobacco Production Chain were highlighted. Established in 2003, the Chamber seeks to develop agribusiness²¹21. Brasil. Ministério da Agricultura, Pecuária e Abastecimento. Câmara Setorial da Cadeia Produtiva do Fumo [Internet]. [acessado 2017 Abr 13]. Disponível em: http://www.agricultura.gov.br/assuntos/camaras-setoriais-tematicas/camaras-setoriais-1/tabaco
http://www.agricultura.gov.br/assuntos/c... and is considered by some respondents as a linkage of the tobacco industry in response to CONICQ. In addition to civil society organizations and representatives of the tobacco industry, the Chamber also has agencies common to CONICQ (MAPA, MDA, MDIC and MRE)²²22. Brasil. Ministério da Agricultura, Pecuária e Abastecimento. Secretaria Executiva. Agenda Estratégica. Tabaco 2010-2015. Brasília: Assessoria de Comunicação Social; 2011.. Existing conflicts due to this concomitant participation of some agencies in both instances and the nominations of representatives common to the Chamber and to CONICQ were cause for questioning regarding compliance with the ethical observations required by CONICQ.

Conflicts have escalated since 2010, when representatives of MAPA, MDIC and MTE frequently questioned the application of FCTC’s guidelines. There was resistance to the implementation of measures related to the regulation of products and the restricted production and export of tobacco without the prior assurance of economic alternatives for tobacco growers.

The tensions of stances between CONICQ members of agencies with large interaction with the tobacco production chain (MAPA, MDIC and MTE) and agencies related to the social sectors (MS and MDA) were highlighted by several respondents:

At the CONICQ, three parties are theoretically are on the production’s side... The Ministry of Industry and Foreign Trade theoretically works with the industry, and the Ministry of Labor. We have a very similar position, the three of us (MAPA, MDIC and MTE)... (DTF 10).

The CONICQ had ministries such as the Ministry of Agriculture... more concerned with the issue of economic interests, the possible impact of the Convention on tobacco exports, on the issue of employment of tobacco production. ... Clearly the MRE, MS and MDA were more progressive... strongly seeking to advance and implement policies (DTF 6).

MAPA, MDIC and MTE’s resistance to support certain measures proposed by the Committee was expressed for most of the period analyzed. However, we observed that the agencies’ stance was also related to the posture of their representatives. MAPA and MTE had greater support or resistance to the implementation of the FCTC in accordance with the beliefs and political choices of its members.

A more prominent stance was identified on the need for advancing the FCTC’s implementation by representatives of the Ministry of Health, with emphasis on ANVISA, CONICQ’s Executive Secretariat and the Health Surveillance Secretariat. Evidence-based advocacy was the main strategy used. Of particular note is CONICQ’s Executive Secretariat elaboration of technical notes involving the scientific review on themes that commonly generated divergences (smoke-free environments, additives, health and tobacco use, crop diversification and packaging standardization)²³23. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). Observatório da Política Nacional de Controle do Tabaco. Documentos e publicações. [Internet]. [acessado 2017 Jun 12]. Disponível em: http://www2.inca.gov.br/wps/wcm/connect/observatorio_controle_tabaco/site/home/conicq/documentos_publicacoes
http://www2.inca.gov.br/wps/wcm/connect/... .

In general, the participation of other agencies focused on the debates on the themes of their agendas, with emphasis on the work of the Ministry of Finance (MF) and the Ministry of Agrarian Development (MDA). The MF has been active in complying with FCTC’s recommendations on prices and levies on tobacco products. The MDA was very active in the search for diversified cultures, also assisting CONICQ’s Executive Secretariat in the organization of activities and publications related to the theme.

Finally, we could identify the importance of some agencies in the articulation with external stakeholders. The Ministry of Health’s Advisory Office on International Health Affairs (AISA) and the Ministry of Foreign Affairs (MRE) were interlocutors with international players, especially in the international WGs and in the Conferences of the Parties (COPs). The Attorney-General’s Office and the Chief of Staff assisted in the regulations and legislation of interest to CONICQ and were fundamental in the dialogue with the Judiciary, Legislative and Executive stakeholders external to the Committee.

Agenda and performing capacity

The topics discussed at the CONICQ meetings (Figure 4) were related to the configuration of the agenda of the National Tobacco Control Policy (PNCT). The debate on tobacco production and crop diversification did not occur at two meetings, evidencing that Article 17 of the FCTC (Support for economically feasible alternative activities) was a permanent item on the CONICQ agenda. There were also frequent discussions on public awareness actions about the harmful effects of smoking, mostly related to campaigns. Issues such as product regulation, illegal trade and prices and levies were discussed in about half of the meetings. The agenda’s construction was influenced by international discussions, with emphasis on the international WGs, the Conferences of the Parties and their preparatory meetings.

Regarding the performing capacity, we can affirm that the institutionalization of the Commission favored its legitimacy as a fundamental instance for the advancement of tobacco control in the country:

It added value, created a valid institutional mechanism, because in times of crisis, in times of political fragility because of political processes, at least you have an established mechanism. Technicians can cling to this to uphold the policy (OSC 3).

... CONICQ provides sustainability to the tobacco control policy. It is an extremely complex mechanism to involve 16 Ministries; they are more than that today... to implement such a policy. This is a worldwide case, it is an absolutely unprecedented management case... (DTF 8).

The engagement of health ministers in CONICQ in the first decade of the 2000s was marked by the process of ratification of the FCTC and the early years of the implementation of the convention in the country and was fundamental to the advancement of the Committee’s agenda. INCA’s leading role in the Committee would also have been important, and some interviewed criticized the shift of some INCA competencies to the central level of the Ministry of Health in 2011.

In spite of these specific changes, there have been advances in tobacco control since 2010. The enactment of Law Nº 12.546/2011 and Decree Nº 8.262/2014, which gave greater rigor to the restriction of advertising, highlighted warnings on the packaging of products and smoking restrictions in closed collective environments²⁴24. Brasil. Presidência da República. Lei no 12.546, de 14 de dezembro de 2011. Diário Oficial da União 2011; 14 dez.,²⁵25. Brasil. Casa Civil. Subchefia para Assuntos Jurídicos. Decreto nº 8.262, de 31 de maio de 2014. Diário Oficial da União 2014; 31 maio.. During this period, the Brazilian policy received international recognition, evidenced by the awards of tobacco control initiatives implemented in the country²⁶26. Organização das Nações Unidas (ONU Brasil). No Dia Mundial sem Tabaco, brasileiro recebe prêmio da OPAS/OMS [Internet]. 2015 [acessado 2017 Jun 12]. Disponível em: https://nacoesunidas.org/no-dia-mundial-sem-tabaco-brasileiro-recebe-premio-da-opasoms/
https://nacoesunidas.org/no-dia-mundial-... ,²⁷27. Brasil. Ministério da Saúde (MS). Brasil recebe prêmio internacional pelo controle ao tabagismo [Internet]. Portal da Saúde. [acessado 2017 Jun 12]. Disponível em: http://portalsaude.saude.gov.br/index.php/cidadao/principal/agencia-saude/17109-brasil-recebe-premio-internacional-pelo-controle-ao-tabagismo
http://portalsaude.saude.gov.br/index.ph... .

The high frequency of some issues in the discussions and the involvement of the responsible agencies with the Committee were not sufficient to ensure progress in specific areas. Noteworthy are difficulties of the MDA in funding and human resources to advance crop diversification actions and of ANVISA’s in ensuring the prohibition of additives. The constraints to ensuring these actions are partly explained by the resistance of CONICQ members who interact with the tobacco production chain and by Legislative and Judiciary barriers, influenced by pressures from industry and organizations related to tobacco growers.

Another impediment refers to the internalization of CONICQ deliberations in some of its constituent agencies. The minutes underscored the concern with the communication to the various ministers on the importance of implementing the FCTC. For example, in the case of the Ministry of Education (MEC), despite its frequent participation in the meetings, there were limitations in the implementation of educational actions on a permanent basis. This may relate to the prioritization of other issues within the Committee and the ministry concerned.

Discussion

Brazil was one of the first countries to establish a mechanism for intersectoral coordination of tobacco control policy²⁸28. Bialous S, Costa e Silva VL, Drope J, Lencucha R, McGrady B, Richter AP. The Political Economy of Tobacco Control in Brazil: Protecting Public Health in a Complex Policy Environment. Rio de Janeiro, Atlanta: Fiocruz, American Cancer Society; 2014., which indicates CONICQ’s pioneering nature in the international setting. Data from 2014 indicate that around 60% of the States Parties to the FCTC adopted this management model²⁹29. World Health Organization (WHO). 2014 global progress report on implementation of the WHO Framework Convention on Tobacco Control. Geneva: WHO; 2014..

The composition of CONICQ was influenced by technical and political criteria. In addition to the participation of government agencies involved in tobacco control actions, stakeholders with institutional power and capacity for political integration were incorporated into the Committee. The hierarchical level, the frequency of participation and rotation of representatives in the CONICQ were also influenced by technical (responsibility for actions) and political issues (the priority given to the topic in the agenda of the agencies involved). Thus, when analyzing tobacco control-related conflicts, Thomson et al.³⁰30. Thomson I, Dey C, Russell S. Activism, arenas and accounts in conflicts over tobacco control. Account Audit Account J 2015; 28(5):809-845.pointed out that the players involved in the policy have different interests and adopt diverse tactics and engagement and influence practices.

As far as the political process in the Committee is concerned, the study identified conflicts between predominantly economic and health-related views. This result is in line with Gneiting³¹31. Gneiting U. From global agenda-setting to domestic implementation: successes and challenges of the global health network on tobacco control. Health Policy Plan 2016; 31(Supl. 1):i74-86., who assigns to the very diversity of the tobacco control network its limited ability in reaching consensus on some strategic decisions. The activities of the Ministries of Agriculture, Development, Industry and Foreign Trade and Labor are very oriented by their role of incentive and protection to the national economy. These agencies have greater proximity to economic agents and may be refractory to policies and strategies that may restrict economic activities. Thus, at various times and in the face of various themes, the stance of these ministries tends to express interests convergent with those of tobacco growers and the tobacco industry, in order to preserve the economic gains from the production and export of tobacco. Therefore, the Internal Rules (2011) and CONICQ’s Ethical Guidelines (2012) were configured as internal mechanisms for the protection of health interests in the face of pressures from the economic sector on the Committee.

In the face of economic interests, some strategies can be adopted for the advancement of tobacco control policies, and they are: to be consistent with the fundamental principles of the global trading system; to affirm countries’ international commitments to the FCTC; to develop consistent scientific evidence; to involve a wide range of stakeholders, including low- and middle-income countries and members of commercial political agreements³²32. Drope J, Lencucha R. Tobacco control and trade policy: Proactive strategies for integrating policy norms. J Public Health Policy 2012; 34(1):153-164..

On the other hand, advocating for the principles of public health and social rights guided the stance of representatives linked to the Ministry of Health and MDA, with emphasis on the prevention of diseases and protection of health and defending the autonomy of family agriculture, respectively. Since the 1980s, the INCA had already coordinated tobacco control policy from an intersectoral perspective³³33. Cavalcante TM. O controle do tabagismo no Brasil: avanços e desafios. Rev Psiquiatr Clínica 2005; 32(5):283-300.,³⁴34. Teixeira L, Jaques T. Legislação e Controle do Tabaco no Brasil entre o Final do Século XX e Início do XXI. Revista Brasileira de Cancerologia 2011; 57(3):295-304. and played a leading role in the Committee, consolidating itself as a technical reference and articulator of the tobacco control network. The importance of the engagement of health ministers as presidents of the CONICQ, whose influence and power were decisive in articulating the stakeholders and favoring advances in politics is also emphasized.

Regarding the main topics addressed at CONICQ meetings, the frequent debate on tobacco production and diversification of crops is emphasized. This may be associated with the range of conflicts around the theme, such as: the indebtedness generated by the integrated tobacco production system³⁵35. Bonato AA. Desafios e potencialidades para a diversificação na agricultura familiar produtora de tabaco. 2013 [acessado 2017 Jan 20]; Disponível em: http://www.mda.gov.br/sitemda/sites/sitemda/files/user_arquivos_64/pageflip-2583697-4429081-lt_Desafios_e_Potenciali-1710093.pdf
http://www.mda.gov.br/sitemda/sites/site... ; harm to farmers’ health and environmental impact of tobacco growing³⁶36. Riquinho DL, Hennington EA. Health, environment and working conditions in tobacco cultivation: a review of the literature. Cien Saude Colet 2012; 17(6):1587-1600.; the international decline of tobacco demand³⁷37. Adamantis E. Associação dos Fumicultores do Brasil (Afubra). [Internet]. Afubra - Associação dos Fumicultores do Brasil. [acessado 2016 Dez 27]. Disponível em: http://www.afubra.com.br/fumicultura-brasil.html
http://www.afubra.com.br/fumicultura-bra... ,³⁸38. Instituto Nacional de Câncer José Alencar Gomes da Silva (INCA). A importância e a urgência da diversificação de produção em áreas que produzem tabaco no Brasil. (Notas técnicas para o controle do tabagismo). Rio de Janeiro: INCA; 2014.; the low political interest associated with the importance of tobacco growing in the economy of the producing locations; and the lack of studies that point out the economic feasibility of alternative crops³⁹39. Riquinho DL, Hennington EA. Diversificação agrícola em localidade rural do Sul do Brasil: reflexões e alternativas de cumprimento da Convenção-Quadro para o controle do tabaco. Physis 2014; 24(1):183-207.. This cross-sectional measure to different sectors (environmental, economic, labor and health aspects) is a relevant factor for the prioritization of this topic in CONICQ’s agenda.

A challenge to the implementation of intersectoral policies that require cross-sectional actions is that the issue in question – in this case, tobacco control – does not have the same priority status in the agenda of the various ministries. While the engagement of some ministries – such as Health – is favored by its high affinity with the theme, other ministries – such as Education – have their own sectorial priorities, to which they channel scarce resources, leaving the issue of tobacco control in the background.

It is worth emphasizing the power of civil society to pressure CONICQ and the Executive, Legislative and Judicial branches. Health advocacy organizations, particularly the Tobacco Control Alliance, have been instrumental in advancing the implementation of the FCTC. However, entities related to the tobacco industry and tobacco growers aligned with the Sector Chamber of the Tobacco Production Chain have been able to contain measures of the National Tobacco Control Policy.

Limitations of the study are as follows: the summary format of minutes, which did not allow a greater detail of the meetings; the possible bias related to the preparation of the minutes by CONICQ’s Executive Secretariat held by INCA; the difficult access to stakeholders in the tobacco industry and tobacco growing organizations; and the limited participation of researchers in CONICQ’s meetings and other events.

Finally, the complex performance of CONICQ is underscored, due to the interaction of sectors with different interests, stance and levels of engagement with tobacco control. CONICQ is a strategic body for the coordination of the National Tobacco Control Policy.

However, its performance capacity is limited by internal factors (resistance of some agencies to the implementation of measures planned in the FCTC and the variable prioritization of its guidelines in the agendas of the agencies involved) and external factors (resistance of the Sectoral Chamber of the Tobacco Productive Chain and organizations linked to the tobacco industry and tobacco growers). We recommend that further studies be conducted to analyze the diverse interests of CONICQ’s stakeholders in their relationship with external players, as well as explore their effective action on specific issues.

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