Tobacco Control in Developing Countries

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Nicotine & Tobacco Research Volume 9, Supplement 3 (November 2007) S447–S457

Review

Tobacco control in developing countries: Tanzania, Nepal, China, and Thailand as examples
Steve Sussman, Pallav Pokhrel, David Black, Matthew Kohrman, Stephen Hamann, Prakit Vateesatokit, Stephen E. D. Nsimba
Received 7 June 2006; accepted 11 April 2007

This paper illustrates case studies of four developing countries and compares them as to relative advancement in tobacco control as prescribed by the Framework Convention on Tobacco Control. Tobacco-control efforts first seem to involve assessment of tobacco use prevalence and passage of tobacco-control legislation (e.g., warning labels). Tanzania, Nepal, and China serve as examples. Eventually, an integrated tobacco-control stance that demonstrates several cycles of tobacco-control activities occurs, as is shown in Thailand. Through these case studies, one can achieve a sense of the direction of progress in tobacco control in developing countries.

Introduction More than 1 billion people worldwide smoke. If current trends continue, 8.4 million smokers are estimated to die annually of smoking-related deaths by the year 2020 (Kaufman & Yach, 2000). Partly in response to the expansion of the World Trade Organization’s Global Agreement on Tariffs and Trade (GATT) to agricultural products in 1994, which opened up international trade as a nondiscriminatory enterprise, tobacco industries now are operating as transnational organizations that have been able to provide tobacco products at relatively
Steve Sussman, Ph.D., Pallav Pokhrel, B.A., David Black, M.P.H., Department of Preventive Medicine, Institute for Health Promotion and Disease Prevention Research, University of Southern California, Alhambra, CA; Matthew Kohrman, Ph.D., Department of Anthropology, Stanford University; Prakit Vateesatokit, M.D., Ramathibodi Medical School, Mahidol University, Bangkok, Thailand; Stephen Hamann, Ed.D., Consultant, International Affairs, Thai Health Promotion Foundation, Bangkok, Thailand; Stephen E. D. Nsimba, Ph.D., Muhimbili University College of Health Sciences (MUCHS), Department of Clinical Pharmacology, Dar Es Salaam, Tanzania. Correspondence: Steve Sussman, Ph.D., Preventive Medicine and Psychology, Institute for Health Promotion and Disease Prevention Research, University of Southern California, 1000 S. Fremont Avenue, Unit 8, Building A-5, Suite 5228, Alhambra, CA 91803-4737, USA. Tel: +1 (626) 457-6635; Fax: +1 (626) 457-4012; E-mail: [email protected] usc.edu

low prices. These tobacco companies seek to team up with local growers, provide incentives to local storeowners, and market themes of sophistication, wealth, or attractiveness that promote a global cosmopolitan cultural demand for tobacco products (Chaloupka & Nair, 2000). Tobacco industry documents indicate a desire for global penetration in markets throughout Europe, Asia, and Africa (Yach & Bettcher, 2000). From 1993 to 1996, exports of tobacco products increased 42%, coupled by a 5% increase in international consumption (Chaloupka & Nair, 2000). Trade liberalization has been associated with increased cigarette smoking, particularly in lowto-middle income countries (Taylor, Chalouka, Guindon, & Corbett, 2000). In May of 2003, the member countries of the World Health Organization (WHO) adopted the Framework Convention on Tobacco Control (FCTC). The FCTC is an internationally based agreement that would commit countries to adopt strong tobacco-control policies. It entered into force on February 27, 2005. A total of 168 countries have signed the treaty, and currently 144 have become parties to the treaty (as of February 6, 2007). To become binding agreements, countries must become parties to the treaty (i.e., ratify the agreement). The FCTC contains no punitive provisions for states that

ISSN 1462-2203 print/ISSN 1469-994X online # 2007 Society for Research on Nicotine and Tobacco DOI: 10.1080/14622200701587078

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ignore their treaty obligations; instead, the FCTC adopts an institutional mechanism of public monitoring of compliance. The FCTC has raised the profile of tobacco control internationally to a level not previously seen. The FCTC contains 38 articles, which lay out the treaty provisions (WHO, 2003). Key provisions are shown in Table 1. The present article provides case studies of tobacco-control efforts in regions of Asia and Africa, illustrating national level compliance in developing countries. We use the FCTC regulations as an organizing guide to assessing level of tobacco control. The four developing country case studies involved in the present study—Tanzania, Nepal, China, and Thailand—came together as presentations at the Second East–West Conference on Tobacco and Alcohol Use organized by University of Southern California’s Institute for Health Promotion & Disease Prevention Research (IPR) in April 2005.
Table 1. Core WHO FCTC provisions against tobacco use.
Exchange of information and technology Article Measure

We first introduce each of the four countries in terms of smoking prevalence and the extent of their tobacco-based economy. Next, we discuss the country-specific tobacco-control efforts. The core obligations required by WHO FCTC concentrate on reducing demand and supply of tobacco in society, reducing exposure to environmental tobacco smoke (ETS), and supporting tobacco use cessation (WHO, 2003). Some of the authoritative review publications on tobacco-control legislation, policies, and interventions, associated directly or indirectly with organizations such as National Cancer Institute (NCI) (e.g., Novotny, Romano, Davis, & Mills, 1992) and Centers for Disease Control and Prevention (CDC) (e.g., Hopkins et al., 2001), were consulted as well. However, the FCTC is an internationally implemented set of policies, whereas the others, while influencing development of the FCTC regulations, have been applied primarily to the United States.

Objective Implement tax and price policies on tobacco products to reduce tobacco consumption. Adopt legislative, executive, administrative or other measures to implement articles 8–13. Protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and other public places. Test and measure the contents and emissions of tobacco products, and regulate these contents and emissions. Require manufacturers and importers of tobacco products to disclose to government authorities the contents and emissions of tobacco products. Ensure that tobacco product packaging and labeling carry health warning and do not promote tobacco use; remove misleading terms such as ‘‘low tar’’, ‘‘light’’, ‘‘ultra-light’’, or ‘‘mild’’ from product packaging; health warnings should contain 50% or more (at least 30%) of the principle display area of the packaging. Promote public awareness of tobacco control issues through effective communication, training, and education; involve health workers, community workers, social workers, media professionals, and educators in awareness campaigns. Ban advertisement, promotion, and sponsorship that would encourage tobacco use and/or cause misleading impressions about tobacco’s characteristics, health effects, and hazards. Promote cessation of tobacco use and treatment of dependence based on scientific evidence, taking into account national priorities. Enforce strong national laws against smuggling, illicit manufacturing, and counterfeiting of tobacco products. Require sellers of tobacco to place clear signs in the shops about prohibition of tobacco sales to minors, to ask for age verification if in doubt; ban sales in places accessible to minors (e.g., close to school); prohibit the manufacture and sale of sweets, snacks, toys in the form of tobacco products. Promote economically viable alternatives for tobacco workers, growers, and, if necessary, individual sellers.

Demand reduction, and ETS reduction, and cessation 6 Price and tax 7 8 9 10 11 Non-price Protection from exposure Regulation of the contents Regulation of tobacco product disclosures Packaging and labeling

12

Education, communication, training, and awareness Advertising, promotion, and sponsorship Cessation and treatment of dependence Control of illicit trade Preventing sales to and by minors

13 14 Supply reduction 15 16

17

Supporting economically viable alternative activities

Note: Articles 6–14 contain the core demand and exposure to ETS reduction provisions in the WHO FCTC treaty. Articles 15–17 and articles 20–22 lay out core supply reduction provisions and ways to increase the exchange of technology and information, respectively.

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We completed searches in PsychINFO (1970 to July 1, 2006) and Ovid Medline (1950 to July 1, 2006), pairing each country’s name with ‘‘tobacco.’’ All relevant articles are included in this review, and we examined both English and native-country language articles. In order to systematize the evaluation of the four countries’ tobacco-control efforts and compare the breadths of their tobaccocontrol policies and programs, we counted the number of control strategies that each country has been able to implement (number of positives) and the number of strategies that it has not (number of negatives) (Table 2). We followed this method, which is similar to meta-synthesis or meta-ethnography, as if each country-specific case study were assumed to be an ethnographic case study (Noblit & Hare, 1988; Davies, 2000). We assigned a positive (+) to a country for a tactic only when the tactic was shown by published literature to be enacted and purportedly used in the country. A negative count (2) was given a country for a tactic which the country did not use at all. Author consensus was established and provided in Table 2. This consensus was labeled as the ‘‘standard.’’ Next, an article review synthesis from each country was provided to four graduate student assistants. These included 1 Nepalese male, 1 Chinese male, 1 Taiwanese female, and 1 U.S. female (whose parents were from Mexico and Vietnam). The raters varied in age from 25 to 29 years old. Tobacco-control strategies were rated on the criteria indicated in Table 2. Each rater’s overall percentage agreement with the standard across 11 categories and across 4 countries was calculated and then averaged across the raters. Interrater agreement with the standard was an average of 84%, suggesting fairly high agreement with the standard.

Likewise, only urban regional data is available to estimate the percentage of persons exposed to secondhand smoke in Tanzania (Mackay et al., 2006). According to the Global Youth Tobacco Survey, 19%–31% of students reported living in homes where other people smoked in their presence, and 26%–38% reported that they were used to being exposed to tobacco smoke in public places (Kilimanjaro region [cities of Arusha and Moshi] and Dar es Salaam) (GYTS—Arusha, 2003; GYTS—Dar Es Salaam, 2003; GUTS— Kilimanjaro, 2003). Tobacco-based economy About 0.08% of Tanzania’s land (about 34,000 hectares) is allocated for growing tobacco (Mackey et al., 2006). Tanzania is one of the biggest producers of tobacco in Africa, ranked third after Zimbawe and Malawi (Hammond, 1997). Tobacco is one of the cash crops that help boost the country’s foreign exchange, contributing about 60% of the Gross Domestic Product (GDP) (Corrao et al., 2000; Jacobs, Gale, Caperhart, Zhang, & Jha, 2000). Tanzania’s tobacco output increased seven-fold between 1975 and 1998 and continues to grow (Corrao et al., 2000; Jacobs et al., 2000). Still, import of manufactured cigarettes exceeds export by 4 million sticks (Shafey et al., 2003). Attempts to reduce demand and supply of tobacco Price-based measure. The total percent tax assessed is 47.2% (average excise tax plus sales tax; Shafey et al., 2003). No available evidence suggests that Tanzania dedicates any portion this tax to tobacco control and health promotion (Mackay et al., 2006). Nonprice measures. Selling tobacco products to minors (under 18) and selling them in locations near schools are legally prohibited in Tanzania (Shafey et al., 2003). However, age verification for sales is not legally required. In the Global Youth Tobacco Survey (2003), 13%–23% of 6th and 7th grade smokers from the cities of Arusha (N52,018), Moshi (N52,323), and Dar Es Salaam (N51,947) reported that they bought their cigarettes in stores and were not refused purchases because of their age. The law requires tobacco product manufacturers to obtain licenses from the Ministry of Community Development and to include health warnings on product packages. The health warnings cover only 6% of the face of a pack. There is a ban on advertising in radio, television, and domestic print media; however, billboard advertising of tobacco products, point-of-sale advertising, and event sponsorships are still permitted (Mackay et al., 2006; Shafey et al., 2003). In fact, British and American

Tobacco control in The United Republic of Tanzania Smoking prevalence The available data on smoking prevalence in Tanzania are based on regional studies carried out in or around urban areas (Arusha, Dar es Salaam, Morogoro, and Moshi). These studies indicate that 1%–5% of women and 21%–27% of men are current smokers in Tanzania (Arya & Bennett, 1997; Bovet et al., 2002; Corrao, Guindon, Sharma, & Shokoohi, 2000; Lore & Lwenya, 1998; Jagoe, Edwards, Mugusi, Whiting, & Unwin, 2002; Keneth, 2005; Mackay, Eriksen, & Shafey, 2006; Maher & Mvula, 1996; Ministry of Health and AMMP Team, 1997; Shafey, Dolwick, & Guindon, 2003). More up-todate smoking prevalence data for adults, based on a representative national survey, which includes rural areas, is lacking for Tanzania.

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Table 2. Number of standard tobacco control strategies used and not used by Tanzania, Nepal, China, and Thailand.
Country Anti-tobacco strategy
1

Tanzania

Nepal

China + (nationally representative) 2 (40%) +(30%) + + (partial ban) + (banned but no age-verification) + + 2 + + (October 11, 2005) 9

Thailand + (nationally representative) + (60%) +(50%) + + (comprehensive ban)c + (banned but no age-verification in rural regions) + + + + + (November 8, 2004) 10

1. Assessment of prevalence + (regional) + (nationally representative) 2 (47%) 2 (25%–50%)a 2. Tax as a % of cigarette price (WHO FCTC recommended: 66% of retail cost)1 3. Warning labels on package (FCTC 2(6%) 2(4%) standard530%, FCTC recommended550%)2 + + 4. Smoking in public locations2,3 + (partial ban)b + (partial ban) 5. Advertisements of tobacco products2,3 3 6. Selling cigarette to minors + (banned but no age-verification) 2 7. Manufacturing licensure required3 8. Tobacco use cessation efforts2 9. Encourage activism efforts such as public protests against tobacco industry1 10. Sign FCTC1 11. Ratify FCTC4 Total of +s of 11 + 2 (aside from World No Tobacco Day) 2 + + (April 30,2007) 7 + + 2 + + (November 7, 2006) 7

Note. 2, anti-tobacco tactic not used; +, anti-tobacco tactic used at least weakly. From left to right columns prevalence of tobacco use among males is 23.0%, 48.4%, 63.0%, and 37.2%, respectively, and is 1.3%, 28.7%, 3.8%, and 2.1% among females, respectively. 1Multiple sources, see text. 2Source: Mackay et al., 2006. 3Source: Shafey et al., 2003. 4Source: World Health Organization, 2007. Note that it was while this paper was being reviewed and revised that Nepal and Tanzania ratified the FCTC. Even though all four countries have now ratified the FCTC, the staggered dates help illustrate the ongoing and dynamic process of the development of tobacco control. aExcise tax varies according to cigarette brand and length of cigarette stick. bPartial ban: ban on radio, television and domestic print media only. cComprehensive ban: complete advertising ban including billboards, point-of sale advertising and event sponsorship.

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Tobacco (BAT) recently donated TSh90 million (approximately US$72,000 as of October 2006) to the government of Tanzania by way of sponsoring the 8th East African Community (EAC) Jua Kali exhibition, which was held in Dar es Salaam in December 2006 (‘‘East Africa: Dar to Host ‘Jua Kali’ Exhibition,’’ 2006). Anti-tobacco educational campaigns in Tanzania have had considerable effects on spreading antitobacco knowledge, especially among youth. Among city youth, 59%–71% reported that during the past year they had been taught about the dangers of smoking in class. In addition, 37%–39% said that in the past year they had discussed in class the reasons why people their age smoke (GYTS—Nepal, 2003). The GTYS also showed that 77%–85% students had seen anti-smoking media messages in the past 30 days. Attempts to control exposure to ETS Smoking in Tanzania is prohibited in health care facilities, and the law requires restaurants to provide no-smoking sections as an option to customers (Shafey et al., 2003). There are no laws against smoking in public places, such as government worksites, educational facilities, and public transportation areas. Tobacco use cessation efforts Aside from annual participation in World No Tobacco Day, there is no available evidence suggesting that encouraging tobacco use cessation programs has gained the attention of public health policy makers in Tanzania (Mackey et al., 2006). FCTC status and summary Tanzania signed the FCTC on January 27, 2004, and ratified it on April 30, 2007 (WHO, 2007). It appears that 7 of 11 key policies have been enacted, but more prevalence data are needed, and some enforcement appears to be lacking.

sticks in 1990, compared with 580 sticks for manufactured cigarettes (WHO Global Status Report— Nepal, 1997). No updated statistics comparing beedi smoking with cigarette smoking are available. It is estimated that 20%–44% of youth in Nepal live in homes where others smoke in their presence (GYTS— Nepal, 2003; Mackay et al., 2006), and 56.4% reported spending time around smokers outside their home (GYTS—Nepal, 2003). Tobacco-based economy About 0.3% of Nepal’s land (about 3,398 hectares) is devoted to growing tobacco (Mackey et al., 2006). Tobacco is considered one of Nepal’s cash crops. The quantity of cigarettes Nepal exports is not known; however, its import of cigarettes in 2000 amounted to 90 millions sticks (Shafey et al., 2003). According to a World Bank estimate (2001), taxes from the cigarette industry contributed about 7% of the country’s total government revenue. Attempts to control demand and supply of tobacco Price-based measures. In 2002 and 2003, the total tax as percent retail price per pack of cigarettes amounted to approximately 25% for imported brands and ranged from 38% to 50% for the popular domestic brands (Karki et al., 2003; Mackay et al., 2006; combination of excise tax, health or smoking tax, and 10% value-added tax). Although the revenue from the health tax is being used successfully on public health purposes, such as sponsoring antitobacco campaigns, funding public health-oriented nongovernmental organizations (NGOs), and running a cancer hospital (WHO Global Status Report—Nepal, 1997; Karki et al., 2003; Magar & Ghimire, 2004), the tax amount has remained fixed for over more than a decade now while money required for medical care has inflated. Nonprice measures. In June 2006, the Nepalese Supreme Court passed a verdict banning advertisement of tobacco products (http://www.elaw.org/ news/advocate/default.asp?article53155). However, anecdotal evidence suggests that this law has only been partially implemented so far. In 1992, the Ministry of Health created a National Anti-Tobacco Committee in collaboration with various NGOs. Nepal’s provisions for tobacco control include regulation of label designs on packaging of tobacco products and requiring tobacco manufacturers to include health warnings and health-relevant messages on packages (Shafey et al., 2003). In practice, however, although all of the manufactured cigarette packets contain health warnings (about 4% of the size of the pack face), because of the presence of

Tobacco control in Nepal Smoking prevalence According to a nationally representative survey, daily smoking prevalence in Nepal was 48.4% and 28.7% for males and females (15 years and older) respectively (Karki, Pande, & Pant, 2003). In addition to cigarette smoking, beedi smoking (indigenous cigarettes made by rolling tobacco in the leaves of the tree Diospyros melanoxylon) is also common in Nepal. Beedi smoking is more prevalent in Nepal than the smoking of manufactured cigarettes: Per capita beedi consumption for individuals 15 and older was estimated at 690

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many unregistered and unregulated tobacco-related cottage industries (Magar & Ghimire, 2004), it is common for beedis to lack any kind of warning label. Local NGOs and medical organizations, in collaboration with the Ministry of Health, have been involved in providing anti-tobacco health education at the school level through lectures and talk shows and at the community level through radio, newspaper, posters, and pamphlets (WHO Global Status Report—Nepal, 1997); 90.6% of youth respondents reported familiarity with anti-smoking media messages; 77.7% said they had been taught about the dangers of tobacco use in the past year; and 55% reported discussing, in class, the negative consequences of tobacco use in the past year (GYTS— Nepal, 2003). In addition, two notable organizations, B.P. Koirala Medical College and Nepal Cancer Relief Society, are engaged in promoting antitobacco activism (UICC, 2005). Attempts to control exposure to ETS People are still largely unaware of the harmful effects of passive smoking in the country (Karki et al., 2003). Currently, it is illegal to smoke in Nepal within government buildings, private worksites, educational facilities, health care facilities, air flights, and public transportation. Tobacco use cessation efforts Nepal has been an annual participant of World No Tobacco Day and Quit-and-Win, the WHO-supported international smoking cessation contest for adults originally designed in Finland (Mackay et al., 2006). FCTC status and summary Nepal signed the FCTC on December 3, 2003, and ratified the treaty on November 7, 2006 (WHO, 2007). It appears that 7 of 11 key policies have been enacted and that national prevalence data have been collected, but some enforcement appears lacking.

cigarettes were imported in 2000, compared with 8.5 billion exported the same year (Shafey et al., 2003). Chinese economy depends significantly on tobacco production and cigarette manufacturing (Hu & Mao, 2002a, 2002b). About 0.27% of China’s land (about 1.4 million hectares) is devoted to tobacco production (Hu & Mao, 2002a; Shafey et al., 2003). Those involved in the tobacco manufacturing industry and retail sale of tobacco constituted 0.6% of the total employed population in 2000 (Hu & Mao, 2002b). The tobacco industry in China is a state-run enterprise (Hu & Mao, 2002a, 2002b). The cigarette tax contributed between 10% and 14% of the total governmental tax revenue between 1983 and 1997, a fairly consistent annual contribution (Hu & Mao, 2002b). Attempts to control the demand and supply of tobacco Price-based measure. Increasing the price of cigarettes has not been used as a means of tobacco control in China. China does not have a sales tax system. Since a retail tax is not levied on cigarettes in China, a product tax makes up the total tax on cigarettes (Hu & Mao, 2002a, 2002b) The selling price exhibits a tax that amounts to about 40% of the value of cigarettes (Hu & Mao, 2002a, 2002b). The real price of cigarettes increased almost by 630% between 1980 and 1997 (Hu & Mao, 2002b). Nonprice measures. In the past decade, China has introduced a number of bans and restrictions regarding advertisement, sale, and use of cigarettes. Advertising tobacco-related products on radio, film, and television, and in newspapers, magazines and periodicals is prohibited (Shafey et al., 2003). Similarly, advertising in public places such as waiting rooms, cinemas, theaters, conference halls, stadiums, and gymnasiums is also prohibited. Selling tobacco to minors (younger than 18) is illegal, though retailers are not legally required to verify the age of the customer. The Chinese government collaborates with other tobacco-control groups in order to advertise health warnings. In addition, the law requires manufacturers to have tobacco manufacturing licenses and to include health warnings on packaging (Shafey et al., 2003); with some variation, such warnings cover approximately 30% of the face of the pack. Only 18%–21% of youth reported that they had been taught in class about the dangers of smoking during the past year (GYTS—Shanghai, 2004; GYTS—Tianjin, 2004; GYTS—Zhuhai, 2004). Attempts to control exposure to ETS According to Tobacco Monopoly Law, smoking is restricted in government workplaces, public worksites,

Tobacco control in China Smoking prevalence Smoking prevalence in China varies from 53% to 67% for men and 1% to 4% for women (Chinese Academy of Preventive Medicine, 1997; Chinese Association on Smoking and Health, 2004; Mackay et al., 2006; Shafey et al., 2003). Tobacco-based economy China is the world’s largest producer and consumer of tobacco products (Yang et al., 1999): 25.3 billion

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and restaurants (Shafey et al., 2003). China’s law on protection of minors bans smoking in educational facilities. China’s implementation guideline for the public place hygiene management regulation does not allow smoking in health care facilities. Similarly, China has regulations prohibiting smoking on public transportation and domestic and international flights and in waiting rooms (Shafey et al., 2003). Enforcement of all of these regulatory efforts remains an ongoing challenge. Tobacco use cessation efforts Initially, programming centered on a brief once-a-year campaign to implement the ‘‘Quit and Win’’ program (Sun et al., 2000; ‘‘60,000 Chinese smokers join Quit & Win,’’ 2004), or isolated tobacco use cessation programs were initiated by local or foreign public health researchers and organizations (Yang et al., 2001; Zheng et al., 2004). Currently, an initiative has been launched in Southwest China’s Yunnan province, led by Dr. Kohrman and colleagues at the Kunming Medical College Tobacco-Control Research Center. It involves the development of a culturally suitable, evidence-based, self-help quit manual, and has involved 2 years of anthropological research and focus group discussions (Kohrman et al., 2005). When partnered with policy-based tobacco-control initiatives, self-help tools are likely to be effective in China, because they are inexpensive to produce, are easy to disseminate, and fit well with quickly emerging Chinese notions of individualized risk management (Kohrman, 2004). This manual uses concepts from the Trans-Theoretical Model (Prochaska, Velicer, Fava, LaForge, & Ruggiero, 1997). Although still undergoing testing, the manual is already being distributed nationwide by provincial-level health education institutes and the Chinese Center for Disease Control and Prevention. FCTC status and summary China signed the FCTC treaty on November 10, 2003, and ratified the treaty on October 11, 2005 (WHO, 2007). It appears that 9 of 11 key policies have been enacted, national prevalence data have been collected, and there are some enforcement and education efforts.

adult samples that indicate the degree of exposure to ETS in Thailand (Mackay et al., 2006). The Thailand GYTS found that 47.8% of the adolescents said they lived in homes where others smoked in their presence and 68.5% reported spending time outside their home where they are exposed to cigarette smoke (GYTS— Thailand, 2004). Tobacco-based economy In 1995, 0.21% of Thailand’s land—about 42,300 hectares—was used for tobacco growing (Shafey et al., 2003). In 1998, 0.181 billion cigarette sticks were exported, while 1.7 billion sticks were imported (Shafey et al., 2003). As of 2001, the Thai tobacco industry consisted of a state-owned monopoly—Thai Tobacco Monopoly (TTM). The tobacco industry contributes 3.5%–4.5% of the total government revenue in Thailand (Sarntisart, 2003, 2006). Attempts to control the demand and supply of tobacco Price-based measure. The retail price of domestic cigarette brands includes excise and value-added taxes. An additional import tariff is imposed on imported brands (Sarntisart, 2004). In 1994, the government of Thailand decided to increase the level of excise tax (Vateesatokit, 2003). Across a decade, this tax policy resulted in an additional US$1 billion for the Thai government while helping to reduce the smoking prevalence in all age groups. The FCTC calls for a tax rate of at least two thirds of the retail price of tobacco. The tax on cigarettes has been raised seven times since 1994 and in 2005 stands at 79% of the base price at the national level (National Statistical Office, 2004), and 60% of the retail price. Non-price measures. The first major tobacco-control regulation in Thailand was the 1989 total ban on advertising and promoting cigarettes. However, in 1991, the Thai government permitted legal importation of cigarettes to Thailand as a compromise position (no advertising allowed) after a 6-year battle with the transnational tobacco industry, particularly the U.S. Cigarette Exporting Association (USCEA). Anti-tobacco forces fought back, and in 1992, the Tobacco Products Control Act was enacted. This act restricted advertising of tobacco products on billboards and prohibited the sale of cigarettes to those under 18, vending machine sales, and the import and sale of smokeless tobacco. The Tobacco Products Control Law also prohibited tobacco companies from advertising through sponsorship of events (Shafey et al., 2003). Another big step towards tobacco control in Thailand involved extensive public educational campaigns. The Tobacco Consumption Control

Tobacco control in Thailand Smoking prevalence Current adult daily and occasional smoking prevalence in Thailand is 37.2% for males, and 2.1% for females (19.5%, overall; National Statistical Office, 2004). There are no available estimates based on

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Office (TCCO), a government entity, was established in 1991. The TCCO and partnership organizations disseminated anti-tobacco messages about smoking and its detrimental effects on health, wealth, and social relationships. Media was effectively used to disseminate these messages. Recently, youth activism against tobacco use has surfaced as another prominent aspect of tobaccocontrol efforts in Thailand. For example, these included public youth demonstrations against the Philip Morris ASEAN Art Awards in 2004 and against convenience stores’ resistance to the Ministry of Health’s new restrictions on tobacco point-of-sale advertising in 2005. Attempts to control exposure to ETS The Nonsmokers’ Health Protection Act of 1992 in Thailand banned smoking in schools and other public places. The smoking restrictions of this law were gradually expanded to include all public transportation, public buildings, some workplaces, and restaurants. Though some locales are allowed to have separate private rooms for smoking, most public offices, including banks and shopping centers, are smoke free. Tobacco use cessation efforts There have been instances of isolated tobacco cessation programs across Thailand since the late 1980s, including one led by Buddhist monks in the district of Mae Sot, Tak Province (‘‘Influence of Religious Leaders,’’ 1993). Currently, tobacco use cessation strategies have been integrated with other measures by the National Committee for the Control of Tobacco use, with a focus on training health care professionals and community health volunteers to motivate smokers to quit (Bhumiswasdi, 2002). Training programs are organized every year across the country, and government assistance conferences are organized that provide opportunities for health professions to discuss ways of setting up smoking cessation clinics (Bhumiswasdi, 2002). The Thai government has prepared a handbook on how to organize and carry out a 3-day long tobacco cessation-oriented camp for those seeking innovative techniques to promote smoking cessation (Bhumiswasdi, 2002). FCTC status and summary Thailand signed the FCTC on June 20, 2003, and ratified the treaty on November 8, 2004 (WHO, 2007). It appears that 10 of the 11 key policies have been enacted, national prevalence data have been collected, activism efforts are noted, and there is some enforcement.

Discussion There are several limitations to these data. First, use of the FCTC criteria may not be without limitations. For example, many researchers might consider the United States as being advanced in tobacco-control efforts. Still, while the U.S. signed the agreement on May 10, 2004, it still has not ratified it. On an international level, however, the FCTC provides by far the best means of comparing countries on level of tobacco-control efforts. Second, more studies have been published on tobacco control in some countries (e.g., Thailand) than others (e.g., Tanzania). In fact, some data (e.g. smoking prevalence) may not be comparable because of the differences in survey measures and sampling methods. In particular, among the case studies presented in this paper, Tanzania shows the lowest reported smoking prevalence—23% and 1.3% among adult men and women respectively (Bovet et al., 2002). Given this relative prevalence, the relatively fewer number of tobacco-control measures used in Tanzania may seem commensurate. However, the prevalence data for Tanzanians (e.g., Mackay et al., 2006; Shafey et al., 2003) are based on studies conducted on relatively small, urban samples (e.g., Bovet et al, 2002), which are unlikely to have adequately represented the more than 37 million people of Tanzania (Central Intelligence Agency, 2006). Clearly, more surveys based on a representative sample are required to establish a better idea of the tobacco use problem in Tanzania. Third, while 84% overall agreement with the standard is reasonably high, there was some disagreement. This suggests either error in care of or preparation for doing the ratings (e.g., no definitions were provided in the rating material) or some ambiguity across persons in interpreting the data. Given the limitations of the data sources and this ethnographic method, the use of available data combined with this coding scheme is still a useful means to begin to gauge country-level tobaccocontrol policy, needs for changes in policy, and monitoring of changes of control policy through repeated measurements over time. Based on the results in Table 2, and considering the different dates of the FCTC ratification, one may speculate that tobacco control in developing countries progresses in three general steps: (a) assessment, awareness, and beginnings of tobacco control often involving public warnings (‘‘awareness’’ step); (b) enactment of several policies but with equivocal national government and local support (‘‘growth’’ step); and (c) enactment and enforcement of a number of policies that take a relatively strong tobacco control stance and demonstrate national government and local activism support (‘‘mature’’ step). According to our evaluation, Tanzania is at the

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end of the first step or beginning of the second step, and Nepal and China are at the second step. In the third step, as illustrated by Thailand, a mature stance toward tobacco control is established; the cigarette tax is used efficiently to reduce cigarette demand and provide a secure funding base for health promotion, cessation is included in national programs, and antitobacco activism is encouraged. These four tobacco control case studies imply to us that tobacco use is now recognized in the developing world as a serious threat to national health. The case studies also suggest that, similar to the more industrialized nations of the West, countries from the developing world acknowledge that tobacco use can be controlled through policy interventions. Moreover, the fact that these countries integrate internationally recommended tobacco-control strategies into their own efforts suggests that they are willing to actively participate in the global movement against tobacco use. The alacrity shown by some of the developing countries to sign and ratify the FCTC further suggests that if an internationally recognized ‘‘codes of conduct’’ regarding tobacco control is established—much like the Geneva Conventions regarding humanitarian concerns—then the countries are likely to view it as an ethical imperative to pledge commitment to such conventions. Furthermore, our descriptions illustrate that tobacco-control efforts vary to some extent across developing countries; a country can be viewed as belonging to a more or a less advanced stage of tobacco control. Classifying countries into such stages facilitates intercountry comparison, which may provide direction regarding which countries are lagging behind others and may need assistance. Future research is needed across a wider sample of countries to consider whether the stage perspective has merit. Although enactment of policies was described, enforcement of policies was not described and is difficult to quantify. According to the first-hand experience of the authors, in Tanzania there is virtually no enforcement of any enacted tobacco policy. In Nepal, most bans and restrictions are not effectively implemented. Smoking within government buildings, private workplaces, and public transportation is still occurring. However, regulations in air flights and health care facilities have been effective. Likewise, for nearly all the policies and interventions enacted for use in China, implementation has been far from complete. Moreover, two of the coauthors have observed numerous sales of tobacco products to minors in rural Thailand. These observations are anecdotal. Enforcement of the FCTC policies is supposed to occur through monitoring, which should be systematic, large-scale,

and representative. This is not being truly accomplished yet in any of these four countries. Other problems exist that may serve as barriers to enforcement. For example, some countries in the developing world, like Nepal, undergo frequent changes in government leadership. Policy legislation under one leadership may not be seriously followed up when another leadership comes to power. In such countries, only a strong system of monitoring supported by the press, anti-tobacco activists, national organizations, and international NGOs can ensure proper implementation of policies. There seems to be a rural-urban divide in developing countries. Urban and rural regions differ vastly in education, health care, knowledge, and state monitoring. While the state is quite effective in enforcing rules and regulations in towns and cities, it is not as effective in monitoring small towns and villages, where tobacco-related laws are often overlooked. We believe this is true in all four countries examined. One final note is that there may be a lack of anti-tobacco activism in developing countries. Absence of activism permits pro-tobacco lobbyists to easily influence the government and persons in business. One possible reason why Thailand is farther ahead in tobacco control than the other countries, despite similar economic pressures, may be the longer and stronger anti-tobacco activism compared with the other countries. Change appears to occur along a developmental trajectory from awareness, to growth of tobacco control, to a mature stance, the last of which might involve extensive activism efforts.

Acknowledgements
This paper was supported by grants from the National Institute on Drug Abuse (#sDA13814, DA016090, DA020138 and P50 DA16094.

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