Abstract:

This research examines the institutional features of Brazil’s National Commission for the Implementation of the Framework Convention on Tobacco Control (CONICQ) and how these institutional features have facilitated and hindered its ability to foster intersectoral tobacco control. In particular, we evaluate the key institutional features of CONICQ starting from when it was one of the key drivers of change and improvements in early tobacco control policies, which helped to make Brazil a world leader in this area. We also examine how the committee has evolved, as tobacco control has improved and particularly elucidate some of the major challenges that it faces to bring together often disparate government sectors to generate public health policies.

Keywords:
Tobacco; Health Policy; National Tobacco Use Control Commission

Introduction

For more than 35 years, health sector proponents have urged governments to establish and utilize intersectoral arrangements as a mechanism to address a range of public health issues. These norms were first expressed in the Declaration of Alma-Ata in 1978, most explicitly articulated in the World Health Organization’s (WHO) 1986 Ottawa Charter for Health Promotion and have been firmly embedded in the WHO Framework Convention on Tobacco Control (WHO-FCTC) ¹1. World Health Organization. Ottawa charter for health promotion. Geneva: World Health Organization; 1986.^,22. World Health Organization. Declaration of Alma-Ata. Geneva: World Health Organization; 1978.. This movement towards establishing whole-of-government approaches to public health policy aligned with work within government, particularly in the United Kingdom, and in the academic literature to break down departmental silos and policy fragmentation across government departments through a restructuring process ³3. Ling T. Delivering joined-up government in the UK: dimensions, issues and problems. Public Administration 2002; 80:615-42.^,44. Clark T. New Labour's big idea: joined-up government. Soc Policy Soc 2002; 1:107-17.^,55. Downe J, Martin S. Joined up policy in practice? The coherence and impacts of the local government modernisation agenda. Local Government Studies 2006; 32:465-88.^,66. Pollitt C. Joined-up government: a survey. Political Studies Review 2003; 1:34-49.. Article 4.4 of the WHO-FCTC urges governments to engage in intersectoral arrangements by determining that “comprehensive multisectoral measures and responses to reduce consumption of all tobacco products at the national, regional and international levels are essential” ⁷7. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. (p. 6). Articles 5.1 and 5.2 further establish the importance of intersectoral arrangements in statements such as “each Party shall develop, implement, periodically update and review multisectoral national tobacco control strategies, plans and programmes…” ⁷7. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. (p. 7) and “towards this end, each Party shall (...) establish or reinforce and finance a national coordinating mechanism or focal points for tobacco control” ⁷7. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: World Health Organization; 2003. (p. 7). These statements encourage governments to establish centralized, intersectoral mechanisms of coordination for WHO-FCTC implementation. Article 5.1 and 5.2 encourage an institutional environment conducive to whole-of-government implementation of the provisions of the WHO-FCTC, with the ultimate aim of having all sectors working to reduce the supply of and demand for tobacco products. In other words institutional design and functioning are recognized as foundational for the implementation of WHO-FCTC ⁸8. Blanke DD, Silva VC. Tobacco control legislation: an introductory guide. Geneva: World Health Organization; 2004..

The WHO-FCTC’s scope creates salient challenges for traditional modes of working within governments and beyond. Such challenges include jurisdictional tensions among the mandates of health authorities and other sectors of government such as trade, agriculture and finance ⁹9. Lencucha R, Drope J, Chavez JJ. Whole-of-government approaches to NCDs: the case of the Philippines Interagency Committee-Tobacco. Health Policy Plan 2015; 30:844-52.. This is particularly relevant for countries like Brazil that are tobacco producers while at the same time attempting to strengthen tobacco control. Very little research has analyzed the conditions under which intersectoral working contributes to mutually enforcing policy across sectors. Research has found that intersectoral collaboration can strengthen policy and programs in areas such as those targeting the welfare of youth by bringing together like-minded sectors such as education, mental health and social services ¹⁰10. Warmington P, Daniels H, Edwards A, Brown S, Leadbetter J, Martin D, et al. Interagency collaboration: a review of the literature. Bath: Learning in and for Interagency Working Project; 2004.. However, the context of WHO-FCTC implementation is unique in that the treaty attempts to bring together sectors with very different relationships to tobacco, ranging from those fostering tobacco production and sale to those attempting to decrease tobacco consumption ⁸8. Blanke DD, Silva VC. Tobacco control legislation: an introductory guide. Geneva: World Health Organization; 2004.. Implicit in the language of the WHO-FCTC is the assumption that tobacco control should concern all sectors of government and result in the harmonization of public policy around the objective of reducing tobacco use. In order to achieve this harmonization one must first understand the dynamics that an intersectoral mechanism creates and then how interactions can be mediated to foster cooperation among the different sectors. This research gap is coupled with the fact that “weak intersectoral coordination” remains a pressing challenge for WHO-FCTC implementation ¹¹11. Nikogosian H, Costa e Silva VL. WHO's first global health treaty: 10 years in force. Bull World Health Organ 2015; 93:211.. In the territory of each Party, the WHO-FCTC and its provisions are embedded in a highly complex institutional context. Our study examines the institutional challenges and opportunities involved in intersectoral coordination and cooperation using the case of the National Commission for Implementation of the WHO Framework Convention on Tobacco Control (Comissão Nacional para Implementação da Convenção-Quadro para o Controle do Tabaco - CONICQ, in Portuguese), Brazil’s intersectoral commission for the implementation of the WHO-FCTC.

We begin our analysis with the premise that an intersectoral mechanism has the potential to move WHO-FCTC implementation along two intersecting lines. The first is by coordinating the implementation of the Convention in the form of domestic legislation and regulations, such as measures taken to reduce demand for tobacco products. The ultimate goal for governments is to incorporate the WHO-FCTC and its guidelines into domestic law. The second potential of an intersectoral mechanism is to shape the culture of tobacco control within government. In addition to legislation and regulations, an intersectoral mechanism can foster process-oriented norms pertaining to the relations within government, and among government, civil society and commercial interests with the goal of fostering a context that is oriented towards health objectives.

The next section describes our analytic framework. This framework describes three constructs that can serve as heuristics in an analysis of the institutional challenges and opportunities of WHO-FCTC implementation. Our analytic framework is constructed with a principal focus on institutional dynamics within government. In this way, we treat government itself as a complex system. Our efforts to identify and articulate the dynamics within government serve to inform the nascent research on whole-of-government approaches to WHO-FCTC implementation.

Analytic framework

The basis for Article 5.2 of the WHO-FCTC, namely the emphasis on the formation of intersectoral coordinating mechanisms by governments, is the recognition that tobacco control requires intervention and action not only by the ministry of health but also by the ministries of agriculture, finance, industry, and trade, among others. WHO-FCTC implementation requires a whole-of-government approach. Although this need is uncontroversial within the tobacco control community there has been little work to conceptualize how such an approach can be established and operationalized to foster the goal of whole-of-government implementation of tobacco control measures. We suggest that to begin such an endeavor, one must identify and analyze the conditions that shape and are shaped by interaction within government. To examine these interactions, we draw from the work of Ostrom ¹²12. Ostrom E. An agenda for the study of institutions. Public Choice 1986; 48:3-25.^,1313. Ostrom E. Background on the institutional analysis and development framework. Policy Stud J 2011; 39:7-27. and the Institutional Analysis and Development (IAD) Framework. Our framework uses three elements from the IAD framework: rules, norms and action situations.

Rules

Ostrom ¹²12. Ostrom E. An agenda for the study of institutions. Public Choice 1986; 48:3-25. (p. 5) defines rules as “prescriptions commonly known and used by a set of participants to order repetitive, interdependent relationships”. Rules are established to “achieve order and predictability within defined situations” by: (1) creating positions; (2) stating how participants enter or leave positions; (3) stating which actions participants in these positions are required, permitted or forbidden to take; and (4) stating which outcome participants are required, permitted or forbidden to affect.

This aspect of Ostrom’s framework is important for analysts of WHO-FCTC implementation because it draws attention to the ways in which government institutions operate as distinct rule-bound entities rather than assuming that “government” is a monolithic entity. There are numerous examples of intra-governmental conflicts that stem from the fact that tobacco serves as both an economic, revenue-generating, employment-creating commodity, while also a health-harming consumer product that must gradually be eradicated ⁹9. Lencucha R, Drope J, Chavez JJ. Whole-of-government approaches to NCDs: the case of the Philippines Interagency Committee-Tobacco. Health Policy Plan 2015; 30:844-52.^,1414. Lencucha R, Drope J, Labonte R, Zulu R, Goma F. Investment incentives and the implementation of the Framework Convention on Tobacco Control: evidence from Zambia. Tob Control 2016; 25:483-7.. It is a common starting point to assume that rules are intrinsically uniform and compatible within government when one assumes that government itself is a singular entity. This is where the literature on institutions and the offshoot body of literature on polycentric governance is illuminating. This literature begins with the premise that “rules (...) directly affect the structure of a situation in which actions are selected” ¹²12. Ostrom E. An agenda for the study of institutions. Public Choice 1986; 48:3-25. (p. 6). Although rules can be found on paper they are also observed in action and are enforced not simply through formal sanction but through social pressures, such as collective endorsement or disapproval.

Norms

Norms are also important to consider in any analysis of institutions and the structures that condition actions taken by individuals. Norms represent “shared concepts of what must, must not, or may be appropriate actions or outcomes in particular types of situations” ¹⁵15. Ostrom E. Understanding institutional diversity. Princeton: Princeton University Press; 2005. (p. 112). Where rules are formalized expectations or prescriptions, such that they may be explicit in the mandates or operating procedures of government departments, norms are less tangible expectations housed in the minds of actors and reinforced by social practices. Norms are inherently “social” in that they require the “attitudes of approval and disapproval, specifying what ought to be done and what ought not to be done” ¹⁶16. Sunstein CR. Social norms and social roles. Columbia Law Review 1996; 96:903-68. (p. 914). Norms become visible when action is taken in a social context. In the case of WHO-FCTC implementation we can see norms at play when for example a government official meets with a tobacco industry representative. This meeting may not break a rule (unless rules of engagement exist for all governmental sectors involved), but will likely be met with disapproval from tobacco control proponents who have worked to establish norms pertaining to tobacco industry interference in government affairs. In this case, you can see the intersection of competing norms across sectors of government whereby the norm in one sector involves meetings between government and the commercial sector and in another the norm characterizes such interaction as interference with public health policymaking related to tobacco. Many work to institute norms into the explicit structure of an institution by embedding them in law or other rules. The establishment of rules from norms allows for a more tangible enforceability of a standard of behavior. One can argue that Article 5.2 of the WHO-FCTC is important because it urges the establishment of a forum for the creation of norms and rules.

Action situation

Both norms and rules come together in what Ostrom calls the “action situation”. She defines action situations as the “social spaces where individuals interact, exchange goods and services, solve problems, dominate one another, or fight (among the many things that individuals do in action situations)” ¹³13. Ostrom E. Background on the institutional analysis and development framework. Policy Stud J 2011; 39:7-27. (p. 11). In this sense the establishment of CONICQ or any other intersectoral mechanism for WHO-FCTC implementation is the establishment of an action situation. It is the creation of boundaries within which actors interact and deliberate on the issue of tobacco control, and specifically on issues of how to implement the provisions of the WHO-FCTC. The mechanism itself becomes an institution embedded in wider social (and political) spaces and can serve as the unit of analysis where one can “describe, analyze, predict, and explain behavior” towards the objective of coordinated tobacco control. The action situation “enables an analyst to isolate the immediate structure affecting a process of interest (…) for the purpose of explaining regularities in human actions and results, and potentially to reform them” ¹³13. Ostrom E. Background on the institutional analysis and development framework. Policy Stud J 2011; 39:7-27. (p. 11). An action situation represents the structure where processes occur and rules are the building blocks that create the structural conditions that shape and are shaped by the actions taken by different actors. Again, intersectoral mechanisms are created for the specific and explicit purpose of coordinating tobacco control measures among government ministries, departments and agencies. This purpose provides the backdrop to analyze how well this body serves the intended objective and a framework that looks to rules and action situations provides the lens to assess the factors that are furthering or hindering movement towards this objective.

While an intersectoral mechanism can bring an advantage of enabling a single articulated position on tobacco control policies among the different sectors of the government, this type of institution must navigate potential, perceived and actual conflicting mandates of members. Brazil was one of the first countries to establish a distinct intersectoral national coordinating mechanism to implement the provisions of the WHO-FCTC. Our study applies this institutional framework to analyze the challenges and opportunities created and faced by CONICQ in implementing the provisions of the WHO-FCTC.

Methods

We conducted in-depth interviews with key informants (n = 25) including legislative members, officials from all of the key ministries (Health, Foreign Affairs, Trade and Industry, Agriculture, Agrarian Development, and the Brazilian Health Regulatory Agency - Anvisa), officials from relevant intergovernmental bodies and civil society representatives. We used purposive sampling to identify individuals who were involved in the development and implementation of the WHO-FCTC, tobacco control measures in Brazil, the activities of CONICQ or the economic aspects of tobacco production. Individuals were included based on the criterion that they were involved in tobacco at the policy level. This meant that we targeted informants who have worked on developing and implementing tobacco control policy (i.e. tobacco was part of the person’s portfolio), or were involved in the economics of tobacco production. We aimed to include a diverse group of informants with the goal of gaining different perspectives on intersectoral working. The authors conducted face-to-face interviews with key informants in Brasília and Rio de Janeiro. The interviews ranged from 45 minutes to 3.5 hours. We carried out interviews up until the moment where our analysis reached “saturation” - the point at which we found consistency in the emerging narratives, or reasonable explanations for any of the inconsistencies.

In addition to the key informant interviews, we conducted an analysis of policy documents, media reports and other relevant documents produced by civil society organizations and government agencies. We systematically searched for public documents pertaining to the work of CONICQ, focusing on documents that highlighted (1) decisions made by CONICQ, (2) relationships between members, and (3) involvement of CONICQ in tobacco control decision-making in Brazil. We received approval in ethics from Brazil’s Ethics Research Committee (CONEP) and from each one of the non-Brazilian investigators’ home institution’s review board.

The following section describes the establishment and operation of Brazil’s intersectoral commission, CONICQ, beginning with the establishment of its predecessor, the National Commission for the Control of Tobacco Use (CNCT) in 1999. The section begins with a brief overview of the history of CONICQ, followed by an analysis of its rule-making and norm-generating function.

Findings

CONICQ: structure and history

The CNCT was established by Presidential Decree n. 3,136/1999¹⁷17. Presidência da República. Decreto nº 3.136 de 13 de agosto de 1999. Cria a Comissão Nacional para a preparação da participação do Brasil nas negociações internacionais com vistas à elaboração de convenção-quadro sobre controle do uso de tabaco, e dá outras providências. Diário Oficial da União 1999; 16 ago.. The purpose of the CNCT was to prepare for and facilitate Brazil’s involvement in the negotiation of the WHO-FCTC which itself began in 1999. The Commission was chaired by the Ministry of Health and included representatives from seven ministries (Foreign Affairs, Finance, Agriculture and Supply, Justice, Education, Labor and Employment, and Development, Industry and Trade) until the addition of an eighth, the Ministry of Agrarian Development, in 2001. The National Cancer Institute José Alencar Gomes da Silva (INCA, in portuguese) served as the secretary of the Commission. The Commission advised the federal cabinet, the Casa Civil, on the development of Brazil’s position during the WHO-FCTC negotiations. Members of the CNCT attended the Intergovernmental Negotiating Body (INB) sessions during the negotiation of the WHO-FCTC (1999-2003).

Following the conclusion of the WHO-FCTC negotiations in 2003, the then President of Brazil, Luiz Inácio Lula da Silva issued a Presidential Decree of 1 August 2003 creating CONICQ. The Ministry of Health, in Ordinance n. 1,662 of 26 August 2003, ensures that the different ministries appoint representatives to the Commission. CONICQ is chaired by the Minister of Health and according to Presidential Decree of 14 July 2010 must include a representative (and a substitute) from each of the following ministries: Health; Foreign Affairs; Agriculture, Food and Rural Affairs; Agrarian Development; Finance; Justice; Labor and Employment; Education; Environment; Science and Technology; Communications; Development, Industry and Trade; and Planning, Budget and Management. The INCA, is also explicitly included and plays the role of Executive Secretary. According to the ordinance that regulates the Commission, each minister nominates one member and one substitute to serve on CONICQ. The Ministry of Health has two representatives (one from INCA and one from AISA - the Office of International Health Affairs) and two substitutes (also one from each of INCA and AISA) and more recently a representative from Brazil’s health surveillance and regulatory agency, Anvisa. The structure and authority of CONICQ has created opportunities to implement the provisions of the WHO-FCTC across all sectors of government. As might be anticipated, however, the same structure has created unique challenges for those seeking maximum alignment between the international obligations set forth in the WHO-FCTC and Brazil’s domestic tobacco control.

CONICQ: rule-making function

The principal claim by advocates of whole-of-government approaches is that intersectoral institutional arrangements that bring together different sectors of government can foster more coherent public policy. For example, in an analysis of tobacco control governance in Brazil during and after WHO-FCTC negotiations, Lee et al. ¹⁸18. Lee K, Chagas LC, Novotny TE. Brazil and the Framework Convention on Tobacco Control: global health diplomacy as soft power. PLoS Med 2010; 7:e1000232. (p. 3) state that “this Commission [CNCT], including all pertinent stakeholders, ensured that tobacco control was embodied in consistent policies throughout government and not only as a health ministry issue”. The structure of CONICQ, including its composition and leadership, has provided the Ministry of Health and related health agencies the opportunity to forge alliances and coordinate policies with other ministries (this structural strength has also served as a limitation which will be discussed in the subsequent section). CONICQ has a broad and encompassing mandate to promote the development, implementation, and evaluation of strategies, plans and programs, as well as policies and legislation, and other measures, for compliance with the provisions of the WHO-FCTC. CONICQ is also involved in coordinating and representing the Brazilian government in the sessions of the WHO-FCTC Conference of Parties (COP), working and study group meetings, and negotiation sessions related to protocols. This explicit mandate to connect domestic policy with the WHO-FCTC provides CONICQ with a unique opportunity to continuously shape and align domestic activities with international commitments as well as contributing to the development of international standards. One of the members of CONICQ noted that its existence has helped elicit support from the Ministry of Finance, which was initially opposed to the issue of tobacco taxation. This individual noted “[a]t the very beginning we had very strong debates with the Ministry of Finance who were not supportive of raising taxes but … today, the Ministry of Finance is one of the most active advocates of WHO-FCTC”. This intersectoral forum served to generate support for the development and approval of the tobacco control-focused Bill 12,546/2011, regulated by Executive Decree 8,262/2014¹⁹19. Presidência da República. Decreto Executivo nº 8.262 de 31 de maio de 2014. Diário Oficial da União 2014; 2 jun., particularly in enlisting the support of the Ministry of Finance ²⁰20. Instituto Nacional de Câncer José Alencar Gomes da Silva. Política Nacional de controle do tabaco: relatório de gestão e progresso 2011-2012. Rio de Janeiro: Instituto Nacional de Câncer José Alencar Gomes da Silva; 2014.. This Bill was the most comprehensive to be implemented in Brazil and included measures such as increased taxation on tobacco products, a minimum price for cigarettes, a comprehensive public smoking ban, an increase in the size of health warnings on tobacco products and a ban on advertising tobacco products at point of sales.

The establishment of this legislation illustrates how CONICQ has served to implement provisions of the WHO-FCTC in the form of formal rules. Although CONICQ serves in an advisory role, participant descriptions of CONICQ suggest that CONICQ has served as a forum to enlist support from different sectors of government to establish substantive tobacco control measures. Apart from substantive rule making (i.e. rules pertaining to tobacco supply and demand), CONICQ has been challenged to establish process-oriented rules pertaining to government-industry relations. Below we discuss how CONICQ has worked to foster institutional norms and rules pertaining to these relations and more generally, to attempt to orient non-health sectors towards the health-objectives of tobacco control.

CONICQ: reciprocity of norm-generating and rule-making functions

One of the reasons for the creation of the predecessor to CONICQ was to protect tobacco control policies from the undue interference from the tobacco industry. Given that Brazil is one of the largest producers of tobacco in the world, it is not surprising that tobacco interests are highly active and politically engaged ²¹21. Food and Agriculture Organization. Issues in the Global Tobacco Economy: selected case studies. Roma: Food and Agriculture Organization; 2003.. It was thought that the different ministries would be held accountable for their positions on tobacco control by mandating that they work together to develop common positions. This structure was meant to insulate tobacco control from pro-industry preferences by orienting the Commission towards health objectives and holding other sectors of government to account in light of this orientation. The Commission also attempted to protect tobacco control from direct industry influence by excluding tobacco industry representatives from serving on the Commission. The structure of CONICQ has followed the structure of its predecessor in its efforts to establish strong norms pertaining to government-tobacco industry interaction. This norm-generating function is reflected in a 2012 resolution by the Minister of Health on behalf of CONICQ which establishes ethical guidelines that are applicable to the members of CONICQ, known as the transparency ordinance ²²22. Administrative Rule 713, of April 17, 2012. Unofficial translation. Tobacco Control Laws. https://www.tobaccocontrollaws.org/files/live/Brazil/Brazil%20-%20Ord.%20No.%20713.pdf (acessado em 15/Jul/2015).
https://www.tobaccocontrollaws.org/files... . Although a resolution does not have the force of law, it represents something of a middle ground between norm and rule. In this specific case we see the Ministry of Health attempting to bolster a norm by establishing a tangible, written, ordinance. The Executive Secretary of CONICQ oversees the implementation of the principles and practices outlined in the ordinance in order to foster an environment in which interactions between different sectors of government and the tobacco industry are open to public scrutiny and do not compromise efforts to develop strong tobacco control measures. This work is “pursuant to Article 5.3 of the WHO-FCTC” and reflects an attempt to create norms that cut across sectors while pursing the formalization of these norms in the form of new rules that hold government officials to account for their interactions with the tobacco industry and industry interest groups. Part of this movement from norm to rule is the provision in the transparency ordinance allowing cases to be referred to the Legal Working Group of CONICQ (GT-Juridico CONICQ). To illustrate how this norm exists in practice one of the participants (a member of CONICQ) highlighted the following example:

“To illustrate the issue of CONICQ today is that we have some working groups on board with CONICQ dealing with legal matters which have been formed by the attorney general’s representative from the different sectors of government. They are getting together to learn about CONICQ issues and their first output was ethical guidelines for the representatives of CONICQ related to Article 5.3 (…) This means that the issue of the relationship between the government and the tobacco industry is starting to change minds. In COP4, the representative of the Ministry of Trade from the Brazilian commission was seen with some representatives of the tobacco industry and we talked to her about it. She cried and apologized”.

Not surprisingly, CONICQ has confronted obstacles while attempting to establish norms and engender rules that apply across sectors. The different mandates and objectives across sectors, particularly the conflicting mandates between health and industry/agribusiness have challenged the uniform establishment of health-oriented norms. One informant emphasized this point by stating that “I think (…) even in CONICQ we have agencies whose representatives are against CONICQ, against tobacco control policy”. According to key informants from the Ministry of Agriculture, the ministry established an intersectoral body called the Sectorial Chamber on Tobacco as a response to CONICQ. The Chamber has publicly opposed efforts to establish strong tobacco control measures, particularly Anvisa’s tobacco additives restrictions ²³23. Fumicultura. Câmara setorial se opõe a consultas públicas da Anvisa. Gazeta do Sul 2011; 29 jan.^,2424. Johns P. Comentário da Aliança de Controle do Tabagismo (ACT) ao posicionamento da Câmara Setorial do Fumo em relação às consultas públicas 112 e 117 da Anvisa. http://actbr.org.br/uploads/conteudo/562_resposta_camara_setorial_final.pdf (acessado em 15/Jul/2015).
http://actbr.org.br/uploads/conteudo/562... . It is clear that the economic sector continues to facilitate tobacco production. Statements made by one of the representatives of the Ministry of Agriculture to CONICQ in a 2015 media interview published on the website Portal do Tabaco (http://portaldotabaco.com.br/) supports the fact that tobacco control norms have yet to supersede norms of tobacco industry support. In this interview Savio Pereira stated that the WHO-FCTC pertains solely to health issues and has “absolutely nothing to do with tobacco producers”, noting, “Brazil would never ban tobacco, which is a strategic resource for the country” ²⁵25. "O Brasil jamais iria proibir o tabaco", diz Sávio Pereira. Portal do Tabaco. http://portaldotabaco.com.br/o-brasil-jamais-iria-proibir-o-tabaco-diz-savio-pereira/ (acessado em 10/Mar/2015).
http://portaldotabaco.com.br/o-brasil-ja... . This statement is particularly noteworthy since the WHO-FCTC does incorporate provisions to support alternative livelihoods for tobacco farmers, but more importantly does not suggest that tobacco production and sales be banned.

There are more than 20 chambers within the government to deal with specific issues, making it difficult to substantiate that the Sectorial Chamber on Tobacco was truly a direct response to CONICQ, although it is perceived as such by several of the key informants and was established just after CONICQ was created. However, it is noteworthy that this Chamber now has implications for the functioning of CONICQ given that both bodies share a common membership. Despite the work to protect CONICQ from tobacco interests the norms have not permeated all sectors. The case of the Sectorial Chamber suggests that entrenched commercial interests may be granted access to a primary forum where tobacco control policy is discussed and it is possible that this common membership across CONICQ and the Chamber may create barriers to CONICQ’s ability to serve as the epicenter of tobacco control in Brazil. This common membership may also reinforce an atmosphere of mistrust among members of CONICQ during deliberations if tobacco control proponents believe that the information they share in the CONICQ forum will be shared with tobacco industry representatives during the meetings of the Sectorial Chamber on Tobacco. One informant who served as a member of CONICQ noted that they were reluctant to share information about the tobacco-related trade challenges against Australia and other countries, noting: “[w]e have discussed this in the working group of legal matters with the attorney general’s office. We need to take this matter for them to study. We created a mailing group to keep them informed on matters relating to Australia, Canada, and prosecution. They are very interested in this process. I think the strategic move is not to discuss it so directly within CONICQ”.

Despite the ongoing challenge of establishing norms across sectors, there is evidence that CONICQ has served as a forum for alignment and cooperation across certain ministries. For example, through CONICQ, the Ministry of Health and the Ministry of Agrarian Development have developed a working relationship and have cooperated on issues pertaining to Articles 17 and 18 (economically viable alternative activities and protection of the environment and people’s health). The Coordinator of the Executive Secretariat of CONICQ and a representative from the Ministry of Agrarian Development authored a joint statement in a prominent tobacco control journal on behalf of CONICQ defending the representation of numerous sectors on Brazil’s delegation to COP4 in Uruguay ²⁶26. Assunta M. Tobacco industry's ITGA fights FCTC implementation in the Uruguay negotiations. Tob Control 2012; 21:563-8.. Participants in our study highlighted the fact that the highest level of government (the President) established CONICQ and this has given the Commission legitimacy, public presence and permanence. One key informant working with CONICQ noted that, “it was very difficult not to support [CONICQ], since we had evidence (…) we have WHO-FCTC commitment (...) and CONICQ was created as a directive from the President”. In other words the fact that the President has mandated the establishment of CONICQ has contributed to its legitimacy across sectors, where member ministries cannot ignore the existence of the Commission on the basis that it is a Ministry of Health initiative or other health department directive. In this way CONICQ’s mandate is structured to ensure its political presence as an advisory body and in principle the credibility it is given through Presidential decree provides its health-oriented mandate with legitimacy. CONICQ arguably represents the creation of a new jurisdiction superimposed on existing jurisdictions, a new action situation (i.e. the bringing together of different sectors of government) with the mandate to facilitate norm-development and rule-formation. In other words the Presidential decree created a multi-sectoral body with the specific function of facilitating the implementation of the WHO-FCTC. This body does not have any formal decision-making power pertaining to policy but represents a forum for consensus-building and the integration of the new culture of WHO-FCTC implementation through norm-generation and rules of conduct for its members.

Conclusion

CONICQ has played an important role in advancing Brazil’s positions at WHO-FCTC COPs and through involvement in working groups that in some cases involved being key facilitators on various guidelines, all of which in turn strengthened its position to articulate domestic policy. Brazil has been a key facilitator for the Article 5.3 guidelines, and Articles 17 and 18 policy options despite an ongoing internal struggle on the best strategy to provide alternative sustainable activities for tobacco growers, and remains a key facilitator for the development of Partial Guidelines to Articles 9 and 10. We have highlighted the role of CONICQ in establishing norms for government-industry interactions specifically and tobacco control more generally that cut across all sectors of government. Another result for CONICQ has been improved coherence in favor of tobacco control from sectors that in the past have opposed certain tobacco control measures, such as the Ministry of Finance. As noted earlier, one interviewee highlighted that the Ministry of Finance became a supporter of tobacco control through interactions with other members of CONICQ. Another example is the relationship that has been forged between the Ministry of Health and the Ministry of Agrarian Development through participation in CONICQ. We highlighted how these two Ministries authored a joint statement in a prominent tobacco control journal on behalf of CONICQ defending the representation of numerous sectors on Brazil’s delegation to COP4 in Uruguay ²⁷27. Perkel C. Feds give farmers $300M to exit tobacco industry. The Toronto Star 2008; 1 ago.. This type of coproduction and cooperation seems to reflect the institutional presence CONICQ is gaining within government. It is clear that institutions are not policy panaceas and bring to the surface existing misalignments and tensions among different sectors. Our findings suggest that CONICQ has an important function in fostering norms and creating rules that protect and promote the government’s ability to create tobacco control law. It also serves as a laboratory to examine how health officials navigate resistance from economic interests while at the same time attempting to sensitize these interests to goals of tobacco control.

In sum, the opportunities created by CONICQ involved building relationships across sectors and mobilizing these relationships to establish policy that integrates and at times shapes the individual mandates of different sectors of government. The basic framework we develop can serve as a useful tool heuristic to understand and analyze the different elements and dynamics of WHO-FCTC implementation from an institutional perspective. We can see how CONICQ continues to facilitate WHO-FCTC implementation by supporting legislation and regulations (i.e. formal rules) that are informed by the substantive provisions of the WHO-FCTC, while at the same time fostering norms pertaining to tobacco industry activity and ultimately a whole-of-government orientation towards tobacco control through the transparency ordinance. We find that CONICQ continues to face important challenges in carrying out these two functions. Despite the establishment of the transparency ordinance that seeks to implement the provisions of Article 5.3 pertaining to tobacco industry interference, CONICQ is faced with a difficult situation wherein some of its members have direct ties with the tobacco industry and promote industry interests. Although in principle the broad inclusion of different sectors of government is lauded as an objective of whole-of-government approaches to healthy public policy, this case demonstrates the inherent challenges of such institutional arrangements. In other words, how do institutions establish mutually enforcing policies across sectors when the different sectors have such divergent perspectives? In order to move towards comprehensive tobacco control such institutional designs must be critically assessed to determine the extent to which the structure of such arrangements facilitates the intended objectives of promoting and fostering tobacco control. It is important to note that the challenge of divergent perspectives and particularly the view that tobacco is a necessary economic commodity is not intractable. For example, in 2009 the federal government of Canada was able to secure a buyout package of USD 300 million to induce tobacco farmers to switch to other crops, a decision that involved different sectors and levels of government ²⁷27. Perkel C. Feds give farmers $300M to exit tobacco industry. The Toronto Star 2008; 1 ago.. This example is instructive of the potential for the government to enlist the support of non-health sectors towards an objective with implications for health. Tobacco production is a particularly difficult problem from the perspective of tobacco control, where supply side challenges are often neglected because of the lack of systemic policy solutions. However, this point should not diminish the importance of sectoral divergence, as it remains a serious challenge. This divergence between sectors, particularly the health and economic sectors, remains one of the most pressing challenges in many tobacco-producing countries ⁹9. Lencucha R, Drope J, Chavez JJ. Whole-of-government approaches to NCDs: the case of the Philippines Interagency Committee-Tobacco. Health Policy Plan 2015; 30:844-52.^,1212. Ostrom E. An agenda for the study of institutions. Public Choice 1986; 48:3-25.^,2828. Otanez MG, Mamudu HM, Glantz SA. Tobacco companies' use of developing countries' economic reliance on tobacco to lobby against global tobacco control: the case of Malawi. Am J Public Health 2009; 99:1759-71..

Ongoing assessment can assist in critically examining the process of norm-generation and rule making. Ultimately this assessment can help facilitate institution building for health policy-making and implementation by identifying strengths and barriers to intersectoral working. National coordinating mechanisms are crucially important for the system-wide implementation of WHO-FCTC provisions. The more that lessons that can be systematically generated from the ongoing functioning of mechanisms like CONICQ, the better governments will be able to establish improved arrangements to achieve optimal health outcomes.

Acknowledgments

We wish to thank Professor Valeska de Carvalho Figueiredo and Professor Silvana Rubano Turci of Center for Studies on Tobacco and Health, Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (CETAB/ENSP/Fiocruz), administrative support from Carla Ferraro, and Yasmín Salazar for her important research assistance earlier in this project; ACT-Brazil for generously providing time, meeting space in Rio de Janeiro, and all of the key informants who generously donated their precious time and knowledge. Thanks also to the Institute for Global Tobacco Control at the Johns Hopkins University (JHU) Bloomberg School of Public Health for funds provided through the Bloomberg Initiative to Reduce Tobacco Use. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Bloomberg Philanthropies or the JHU Bloomberg School of Public Health.

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