Follow the Data Podcast Episode 10: The role of countries in the global tobacco crisis
As the World Health Organization and people around the globe celebrate World No Tobacco Day, we invite you to join us for part two of our series on tobacco control. Over the last ten years the Bloomberg Initiative to Reduce Tobacco Use has successfully supported 59 countries in passing laws or policies, reaching nearly 3.5 billion people and saving an estimated 30 million lives.
Through the support of a few of our long term partners like Campaign for Tobacco Free Kids and The International Union Against Tuberculosis and Lung Disease, also referred to as The Union, Bloomberg Philanthropies is working globally to promote evidence based policies like creating smoke-free public spaces, banning advertising of tobacco products, and raising the price of tobacco through taxation – to reduce tobacco use in low and middle income countries.
In this episode we’ll go in depth on the ways how countries are passing critical laws to protect the public and taking action to implement policies.
Yolonda Richardson, from the Campaign for Tobacco Free Kids and Jose Luis Castro, from The Union, join Neena Prasad of the Bloomberg Philanthropies’ Public Health team to discuss.
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Katherine Oliver: World No Tobacco Day takes place each year on May 31st.
This special day was created by the World Health Organization to inspire those around world to band together to say no to tobacco and take action to confront the global tobacco crisis.
You may recall in a previous episode, we went in depth on tobacco control and explored how Bloomberg Philanthropies is working with partners around the world to protect billions of people from the harmful effects of tobacco.
In part two of our series on Tobacco we’ll take a look at the Bloomberg Initiative to Reduce Tobacco Use, which has successfully supported 59 countries in passing laws or policies, reaching nearly 3.5 billion people and saving an estimated 30 million lives – this progress would not have been possible without the support of our partners.
In this episode, we’ll hear how our partners at The Campaign for Tobacco Free Kids and The International Union Against Tuberculosis and Lung Disease, also referred to as The Union – Their working globally to promote evidence based policies like creating smoke-free public spaces, banning advertising of tobacco products, and raising the price of tobacco through taxation – to reduce tobacco use in low and middle income countries.
We welcome, Neena Prasad, a member of the Bloomberg Philanthropies Public Heath team, who is joined by Yolonda Richardson, from the Campaign for Tobacco Free Kids which is a leading force in the fight to reduce tobacco use, and Jose Luis Castro, from The Union, an international institute focused on tobacco control, tuberculosis, lung health, and HIV in low-and middle income countries.
They are all working together to help countries around the world implement policies to reduce tobacco use.
Neena Prasad: Thank you both so much, Yolonda and Jose, for being with us today. A big focus of the Bloomberg Initiative is to put in place evidence-based policies to reduce tobacco use in low and middle income countries. And we promote policies which are part of the World Health Organization’s MPOWER package, and these include things like making all public places smoke-free, banning advertising of tobacco products, raising the price of tobacco through taxation. Can you talk to us about what role your organizations play in promoting those policies around the world?
Yolonda Richardson: Campaign for Tobacco-Free Kids, we work very closely with civil society groups on the ground to implement the policies you’ve just outlined. And so, in that respect, we provide really two sort of streams of support to those groups.
The first stream of support which we do in conjunction with The Union, Vital Strategies, is to provide financial support to these groups. We go into these countries and we try to identify the groups who are working on the issues or who are best positioned to work on the issues and we provide financial support.
The second piece of the work that we do with these groups is to really work with them to provide a whole range of technical support. And that technical support is to help these groups use global best practices in their advocacy work.
That includes helping them with communication strategies, helping them with legal strategies, helping them to design campaigns, and a whole plethora of things they need in order to move policy change within their countries.
Jose Luis Castro: The Union as a member of the initiative, our role is primarily to provide technical assistance to the countries, and also to provide financial support to the international grants programs. This grants program has been managed together with the Campaign for Tobacco-Free Kids and has been an important part of the initiative. When the initiative started ten years ago many of these organizations were actually very small, maybe had one or two individuals, had never managed more than $5,000.00 or $6,000.00 in grants. So, the grants program helped these organizations develop the infrastructure that was need to first of all manage an initiative with substantial resources, but also to hire additional staff, additional people to take care of the work nationally.
The second part of the work on the technical assistance that we provide, it’s training on the programmatic aspects of the initiative, the best practices of tobacco control, legislation, as well as the management of the organization. That was crucial as we developed these organizations during the course of the initiative. Over 125 organizations have been developed through this grants program, the capacity building throughout the world, and 28 ministers of health have received this type of support, which has enabled the initiative then to implement effectively the program of activities in each of in the countries in which we work.
Neena Prasad: Can you transport us to a country where the initiative works and translate this description you’ve just given us of your organizational missions into what that actually looks like on the ground?
Yolonda Richardson: We’ve worked in some pretty diverse countries, as you well know. A lot of these countries as by definition are low and middle income countries, so they often go through periods of political unrest or political changes that are quite substantial. Working in both China and Russia, which are pretty closed countries in terms of the context for how we could work. In both we’ve seen some really substantial successes that I think are worthy. The Beijing campaign I thought that one was really quite extraordinary.
We were pretty intimidated moving into China. It’s a closed political structure. There aren’t a lot of non-governmental organizations that work in the country. We had to work with what are called government NGOs, known by the lingo of China as GONGOs, which means that the government was very much engaged and very much involved in the notion of kind of making sure that the government’s perspective about the policy change was very much included in how we worked with those NGOs. But over time we would invest in quite a number of earlier effort in trying to bring a public case for tobacco control – We spent a lot of time kind of sowing the ground for policy change.
We got an opportunity to begin to do some work at the city level. The Union did a lot of work at the city level, as well our partner there. And we began to detect in Beijing a willingness and interest in trying to do a smoking ban in public, and we worked very, very closely there with the local government to make sure that they were able to do it.
The interesting thing about China, not only was it a closed operating environment, but the tobacco industry is actually a government company.
This created all kinds of challenges and all kinds of nuances throughout the fight of trying to get Beijing smoke-free. But I think it is a good example of kind of how you have to constantly address your strategies and your tactics, how important it was for us to have the work and focus of all of the Bloomberg partners. The World Health Organization played a major leadership role, The Union did as well, in terms of really helping us begin to help support Beijing to do the most progressive law that they could. And in fact, now the Beijing smoke-free law is one of – it’s the gold standard for tobacco control around the world for city-based work.
Neena Prasad: That’s a really great example. One of the overarching aspects of our philosophy here at Bloomberg is to follow the data, and if you can’t measure it, you can’t manage it. Can you talk about how you use data to prioritize, to measure how we’re doing?
Jose Luis Castro: The Union as a scientific organization, we are also a very data-driven organization. We use the data for development of policies.
The challenge that we faced at the beginning was that the quality of the data in the countries, whether this was reliable data that could be used. But since we have the ability of the Global Adult Tobacco Surveys – or, also known as GATS – the governments have accurate data to make the decisions.
For example, in Vietnam the recent release of the GATS indicated that they first have led to a stop in increase in smoking prevalence. But it also indicated that more needs to be done to bring the numbers down, and we tailor our programs for this to happen, looking at each indicator and their effectiveness. I think that the GATS have been used in a number of the countries, to understand the situation and smoking prevalence in the country, and providing quality data to the government and also the partners to adjust our initiatives to – and to ensure that we are implementing effectively in those countries.
Yolonda Richardson: What’s unique about tobacco control is that we faced a pretty strong opponent in the tobacco industry. One of the things that is so important, I think, for this initiative and for CTFK and for all the partners who really are very data-driven and science-driven is to make sure that we are in the public discourse addressing the misinformation that the tobacco industry often puts out there. They have a consistent set of both tactics and a consistent set of messaging. And so, part of our job is to make sure we are positioned to be able to both preempt those messages by already having messages out there – that would shape the tobacco discourse in a way that the tobacco industry cannot manipulate or misrepresent what is going on in a country around tobacco control.
The example that Jose just mentioned about using the Global Adult Tobacco Survey is one that is so critically important for us because it really does help crystallize at a particular moment around the release the full country’s attention on what the prevalence data is.
When countries are able to focus on that way about what their prevalence burden is it gives us an incredible opportunity to then drive the need for policy reform. When you have your own data and your own information coming back and saying that this was an effective approach to drawing down prevalence rates, it’s so much more powerful to local countries. When we have data points and local data that helps country to be able to show that a problem exists and there are policy prescriptions that can be effectively used it’s a win for that country, but it’s a win for our global effort.
Neena Prasad: You’re reminding me of Brazil, and we saw a very similar thing there, where in between the two GATS surveys, the only policy that had been implemented, really, was a tobacco tax.
We saw a significant decline in consumption and could pretty confidently say that that was due to the tax. I think there are multiple ways that we use data in this initiative. Yolonda, you mentioned the industry and being really well-prepared to (a) anticipate what they may do and (b) to react to their messaging and practices. Can you talk a little bit more about industry interference in our work?
Yolonda Richardson: Well, you know the adage “The best defense is offense,” right? So, we’ve really changed our model and approach and our conceptual framework. It sounds simplistic in some ways to say this, but we really in the early days were really just trying to counter the misinformation. A lot of our energy was around trying to train our partners in the country to be able to anticipate what the information would be and respond to it when the industry would do it.
Over time we realized that the tobacco industry, I must say, is not incredibly creative in terms of the kinds of strategies they use or even the arguments they use. That put us in a good position to be able to help our partners know when they – you want to argue for a smoke-free law they’re going to claim that there are economic impacts that hurt restaurants, bars, and other hospitality venues. So, we were out there and prepared.
The work now has shifted from countering industry misinformation and is instead trying to get in front of it so that we’re establishing the narrative with respect to a policy fight or a policy conversation, and getting out pretty early when we know we’re going to be moving a policy effort forward. Even more than being preemptive when you’re in a policy fight, we are increasingly trying to invest in efforts to make sure that the tobacco industry is not even perceived as a legitimate stakeholder in the policy process in the first place. So, we’re really trying to put out information about the kinds of tactics that they’ve done around the world. Trying to really put the context of the policy debate on our terms rather than on their terms. And we’ve been pretty successful in a number of countries. We released two reports.
One was focused on trying to document what the tobacco industry has been doing around schools with children to show that they are in fact trying to put their products close to schools and entice schools. They always deny that they would ever reach out to children: “We would never do that. We’re good corporate citizens.” And in fact, we have lots of documented proof that they’re doing exactly that. It changes how the public perceives them and it puts us in a better position when we’re actually trying to get out there and advocate and it discredits them when they’re trying to sell the misinformation. So, before they can open their mouth, we’ve already characterized them in a way that is truthful. It’s not a dishonest characterization; it’s an accurate characterization.
Jose Luis Castro: The Union, as a capacity business organization we’ve done a lot of work in helping countries meet the obligations of the treaty of the Framework Convention for Tobacco Control. We have worked in preparing the guidelines on how countries implement dealing with the industry interference in tobacco control by developing a set of guidelines for implementation of the Article 5.3, which addresses the issue of industry interference in tobacco control.
As Yolonda mentioned, the industry is pretty active and pretty strong, which can seem overwhelming to those working to promote tobacco control policies.
But when we confront the industry with data, we can push back at the efforts of the industry to derail any of the work that has been done to implement effective tobacco control policies in the countries.
Yolonda Richardson: Jose, you reminded me that one of the things that the industry does when all else fails, they’ve lost a policy fight, is that they try to intimidate governments by litigating the matter. And I should just mention that that’s something that I think has been incredibly unique in the Bloomberg Initiative, which is resourcing a set of both in-country and global network of lawyers who could actually help countries to be able to defend their laws and get in front of that. So, there are examples all around the world of how the industry has proceeded to sue countries as a way to intimidate them from moving forward with enforcement or to dilute the laws that they’ve already passed, with this sort of notion that if they dared regulate them, they would proceed to sue both on domestic – on the basis of domestic legal challenges, but also in terms of increasingly international legal challenges.
I have to say the tobacco control movement supported by Bloomberg has been amazingly successful. We have a real track record now of helping to make sure countries know that there are resources out there to help them defend their laws, but us also on the winning side, which is great for the field and great for countries.
Neena Prasad: I think that ten years in we all know that changing the law is only half the battle. Then, you have to implement it and enforce it. Can you talk to us about what that looks like? And what are the challenges around that?
Jose Luis Castro: One example, if I can go back to India with their national tobacco control law, which is quite comprehensive, we have an example of a law that has been passed in the country, but at the time of implementation the challenges with enforcement have been significant and very difficult to address across the country. And this is one of the challenges that we see in many countries. We have a law that is effective that has all the right components, but the actual implementation by the agencies that are responsible to make that happen doesn’t happen as it was intended in the law. This is where the work of organizations like the Campaign for Tobacco-Free Kids and all their partners in the initiative is important in raising the awareness in the country and working with those other agencies responsible for enforcement of the law to ensure that those provisions are implemented effectively.
Neena Prasad: Speaking of India, here was a really big win this year, we hope – when large graphic health warnings were finally placed on tobacco packages. And I think this win gets at points that is having the law isn’t enough. You need regulations, and we saw a lot of delay there. And the second is just the power of civil society in finally making that happen. Yolonda, could you talk to us a little about what happened there and what that looked like?
Yolonda Richardson: For those of you who don’t know about the term graphic health warnings, they’re essentially consumer warnings that are placed on packages of cigarettes. And they are not words; they are actually pictures. The more graphic, the better the science tells us, the bigger the science tells us. And it is absolutely critical, particularly in low and middle income countries where there may be low literacy rates. And so, therefore you can get the consumer warning without words.
The graphic health warning fight in India this last time was quite intense. When the now Modi government came into power two years ago then-Minister of Health was a very dynamic, really tobacco control advocate: Harsh Vardhan. And he came in immediately and he said, “I want India to be a real global leader in tobacco control,” and so asked – reached out to civil society and other stakeholders, like “What do we need to do?” – what can – what kind of things we could do.
All of us in the Bloomberg Initiative offered some real examples of ways we could move forward, but he decided that one of the things he wanted to first work on were graphic health warnings, which was great for us as tobacco control movements, because at that time Thailand had an 85 percent graphic health warning. Sri Lanka had an 85 percent graphic health warning.
Nepal, a tiny little country, had decided it was going to have a 90 percent graphic health warning. Pakistan then announced it was going to have an 85 percent graphic health warning.
India then came in and said, “We’re going to do an 85 percent pack warning. The tobacco industry just went bonkers.
They decided that they wanted to shut down production, which they in fact did. They had a legislative committee that came out and just even challenged that tobacco causes cancer, and that played out in the media. And then, because of that, then they had this whole conversation about kind of like the ties of people on that committee to the industry, and we did a real – a series of exposes.
It got so intense, the media attention around this, that it had a name – Tobaccogate – because it was so much the conversation. It populated – and the average person in India was actually talking about tobacco control.
So it made immense pressure on the ministry to finally get the regulations out the door.
The thing that really pushed it over, there was a lone civil society in Rajasthan, a state in India, that filed a piece of litigation forcing the ministry to tell why they had not in fact implemented this. And what really moved the bar, we believe, in India was that as a result of this suit the Minister of Health was afraid to be in contempt of court. And so, all of a sudden the machinery started working.
Now, the media stuff absolutely worked. The outrage absolutely worked. All of it was a coordinated campaign. But we really feel like that was the turning point, when they really felt all of a sudden that they were personally going to be held accountable for not moving this law forward. The tobacco industry was doing what we called forum shopping.
They were going to state after state to find other states that would then have an opposing opinion And so, at one point literally there were 27 different lawsuits going on in India from all of these different states all around India.
What we were able to successfully do with civil society and the Ministry of Health and other partners was to have all of those suits then sent up to the Supreme Court of India as one action they all did get combined into one piece of litigation that went before the Supreme Court, and we got a very, very positive decision out of the Supreme Court.
So, we get this very positive victory out of the Supreme Court. Wonderful language that really just kind of really nails the industry. But the Supreme Court decided to remand, or in other words push it back to the lower court for final resolution, and now again it’s sitting in the state of Karnataka for final resolution.
Neena Prasad: And how many cases are you up to now?
Yolonda Richardson: We’re now up to 54 different cases. The industry is still forum shopping, all kind of consolidated. The good news is that the Supreme Court decision was strong, the language was strong, but they said that the government could go ahead and implement the pack warning. So now, we have 85 percent graphic health warnings actually on packs in India, making the case much harder for the industry to say, “It’s just not possible. There’s no way.” We’ve actually documented that it actually is happening: Even small production companies are able to get the warning labels out. But technically, it’s still being litigated.
Neena Prasad: So, final question: We have a lot to do in the countries where we work. How do you prioritize which policy you’ll work on?
Jose Luis Castro: In terms of prioritizing the policies, depending on what is more opportunistic in the country, that varies from the countries that are at the stage of introducing a major change in the policy to the countries that are just into the development of a regulation or moving forward with implementation of a particularly policy. So, it’s a question of assessing that readiness and what is – what are the resources available to assist the country.
Yolonda Richardson: I completely agree. It’s really trying to look at whether or not a country is politically ready and there’s sufficient political support to move it forward. If that’s there, we move forward.
Neena Prasad: This has been a really interesting conversation and I on behalf of Bloomberg Philanthropies would like to thank you, Yolonda and Jose, for being with us today.
Jose Luis Castro: Thank you.
Yolonda Richardson: Thank you.
Katherine Oliver: We hope you have enjoyed part-two of our series on Tobacco Control as we took an in depth look at how countries are taking action to implement policies and passing critical laws to protect the public.
If you’d like to learn more about the Bloomberg Initiative to Reduce Tobacco Use, visit bloomberg.org.
Thank you for listening to our podcast – if you haven’t already, subscribe and send us your feedback at firstname.lastname@example.org.
As our founder Mike Bloomberg says, if you can’t measure it, you can’t manage it. Until next time, keep following the data.
Special thanks to producers and editors Kelsey McCarthy, Ivy Li, Lindsay Firestone, and music composer Mark Piro and our engineer David Sucherman.