By Dr. Nimesh Samarasinghe
The harms associated with tobacco use are well documented in the scientific literature and articles published in national newspapers. However, less information is available on the politics inherent in tobacco control policymaking and the factors that explain tobacco control policy outcomes. This article will concentrate on this information gap, focusing on the key stakeholders, ideologies, power and politics inherent in tobacco control policymaking in Sri Lanka.
I am applying a policy science approach that encourages diversity of perspectives to understand tobacco control policies situated in the history as opposed to content analysis of the prevailing national tobacco control policy. Therefore, I will endeavour to answer questions such as; who are the tobacco control policy actors?, who has been influential (or not)?, what are some of the beliefs and ideologies of tobacco control policy actors?, and have there been any consensus and contradictions inherent in tobacco control policy-making?
Paying close attention to the external environment and how external factors influence the national stance taken on tobacco control is an important area often ignored in tobacco control policy analysis. Two main external influences on tobacco control include transnational tobacco companies (TTC) and external health experts, often led by the World Health Organisation (WHO). While the former is more concerned about increasing profits, the latter focuses on tobacco control strategies, primarily aiming to reduce the harm caused by tobacco use.
Sri Lanka signed and ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2003. Countries signatory to the FCTC are expected to give priority towards protecting public health and address the demand and supply of tobacco through a multitude of strategies. The six key components of the WHO tobacco control framework, which is popularly known as the MPOWER package include; monitoring tobacco use and prevention policies, protecting people from tobacco smoke, offering help to quit tobacco use, warning about the dangers of tobacco use, enforcing bans on tobacco advertising, promotion and sponsorship, and raising taxes on tobacco.
Although a signatory to the FCTC, Sri Lankan action to implement the FCTC convention generally has been slow in some areas and swifter in others. Legislative changes to give effect to the WHO FCTC have been realised faster when national legislation was passed in 2006. This includes measures relating to restrictions on smoking in public places; packaging and labelling requirements; tobacco advertising, promotion and sponsorship; establishment of the National Authority on Tobacco and Alcohol (NATA); and offences and penalties. Although national dissent against tobacco use had existed prior to signing the FCTC and is described further in this article, it was the WHO which influenced the passing of national legislation against tobacco and the establishment of (NATA).
Despite this, implementation of the legislation concerning tobacco control was slow to begin with e.g. introduction of pictorial health warnings (PHW) on the packaging of tobacco products and increase in tobacco taxes as per WHO standards. According to research conducted in low and middle income countries, tobacco control policy implementation lag is attributed to the influence of powerful transnational tobacco companies (TTCs) lobbying politicians and misguiding them with information and presenting or funding research that is tainted with the economic benefits of the tobacco industry and the contribution it makes to the economy through taxes and the livelihoods created.
These take place in the context of other external economic development agencies such as the World Bank arguing for spatial restrictions to reduce opportunities to smoke and advocating on raising taxes on tobacco as a means to reduce the consumption. Such strategies are particularly aimed at young smokers who are especially price sensitive. Across all smokers in low and middle income countries, the World Bank estimates that a 10% rise in price will cause an 8% decrease in demand. Additionally, the IMF also recommends increasing taxation of tobacco as part of their economic stabilisation programmes. These are external drivers and it is noteworthy that Sri Lankan policymakers do not act in isolation – they are influenced by a number of external pressures.
Presidential commissions on tobacco control
Now, let us go back and look at the national context, particularly presidential interest on tobacco control. The first Presidential Commission on the prevention of alcohol and tobacco came to an abrupt end following the assassination of President Premadasa in 1993. Later, President Kumaratunga established a new committee to draft a national policy on tobacco and alcohol. This committee was significantly influenced by academics and medical doctors who had a keen interest in reducing the harms caused by both substances. Central to the committee was a concern around the increase in non-communicable diseases such as stroke, cancer and coronary heart diseases and link to tobacco and alcohol use. The need to regulate the tobacco and alcohol industries from the perspective of public health protection was supported by this committee.
The committee’s recommendations won cabinet support and legislation to implement these recommendations was drafted and gazetted by the Parliament as far back as September 1999. However, as Olcott Gunasekera describes “an invisible hand prevented its coming on to the order paper before Parliament was prorogued in October 2000”. In other words, the committee’s advice was not translated into policy or any significant action which suggests that legitimisation of scientific advice was subject to other interests and influences.
Policy advocacy and community mobilisation
Community mobilisation against tobacco use had been taken forward by some Non-Governmental Organisations (NGOs), prominent Buddhist monks, academics and medical doctors. An NGO-launched campaign in 1991 under the theme “vote for anyone who supports alcohol and tobacco control policy”, aimed to raise the issue onto the political platform to affect a change in policy direction. This appeal was repeated at every parliament, provincial and local government election until 1995, hoping to raise the tobacco control issue onto the policy agenda.
The voices against tobacco use grew incrementally by early 2000. NGO activities against tobacco primarily included public-targeted prevention campaigns and lobbying of Government departments, political parties and civil society organisations. They discouraged smoking and encouraged legislative action to regulate the tobacco industry. Some NGOs had support from senior medical doctors and the clergy, particularly those who supported temperance (sobriety). These supporters held core positions in Government policymaking systems with established links to the President. It is not an undertaking of this article to reveal the identity of these actors but presents the importance of their links and pivotal roles in setting the policy agenda.
Activities conducted by NGOs and community organisations framed both tobacco and alcohol as threats to the country’s development. According to some research studies done, as high as 30-40% of the income of the poor in Sri Lanka was spent on tobacco and alcohol. This was a cause for concern as meagre financial resources were removed from the survival of the poor. Policy advocacy and community mobilisation had strong foundations in the belief that tobacco use is a threat to the socio-economic development of Sri Lanka. This is in addition to the obvious knowledge of the health harms caused by tobacco leading to familial economic deprivation.
Regulation of the tobacco industry has been the obvious policy choice advocated by grass root organisations. It was within this context that NGOs lobbied politicians and religious leaders across the country during mid-2000s to increase support to enforce PHWs on the packaging of tobacco products, increase taxes and regulate tobacco advertising. Lobbying activities also included tobacco health education to, and mobilisation of thousands of Samurdhi officers to obtain their signatures on petitions in support of implementation of tobacco control legislation. Additionally, peaceful protests and public campaigns on the harms caused by tobacco use had been conducted by community activists. All these actions were aimed at politicians and decision-makers in Government.
A tobacco farmer in Sri Lanka
Political interest in tobacco control
Political interest in tobacco control peaked during President Rajapaksa’s tenure. In particular, the Jathika Hela Urumaya (JHU), which advocated the righteous society, can be regarded as a major stakeholder who influenced the tobacco control policy landscape during Mahinda Rajapaksa’s presidency. The JHU was concerned about the moral decay in the country resulting from breaking the five precepts of Buddhism. A righteous society pledged to be reinforced by the JHU would include abstinence from intoxicants. In addition to illicit drugs and alcohol, tobacco was considered as an intoxicant that compromises the moral values of Sri Lankans.
The Mahinda Chinthana election manifesto was influenced by the JHU and titled its first chapter as ‘Towards a disciplined society,’ highlighting the importance placed on good citizenship. The problems of illicit drugs, alcohol and tobacco were addressed in the same chapter. It was within this context Dr. Omalpe Sobhita Thero tabled a Private Member’s Bill in 2005 with the primary intention of regulating the tobacco and alcohol industries. It addressed the tobacco and alcohol policy recommendations from the Kumaratunga presidential commission. Shortly afterwards, the ‘Mathata Thitha’ campaign was launched and gained traction.
Within this blanket approach (addressing illicit drugs, alcohol and tobacco), the ‘Mathata Thitha’ campaign also spoke to the concerns of female voters in the south and midlands of Sri Lanka. Both areas were adversely affected by the influence of the illicit alcohol industry but tobacco was additionally perceived as having a greater role to play in the disruption and income of families. Accordingly, any state intervention to achieve an ‘intoxicant free’ society gained public support, particularly from women in rural communities. While this was government rhetoric and became a political campaigning tool, the mood for change in the tobacco control policy landscape did grow and was supported by the JHU.
The tobacco industry tactics
Although tobacco control was raised onto the policymaking agenda, the tobacco industry engaged in tactics to defend and promote their business interests. Some of its prominent businessmen in Sri Lanka were well-known to office-bearers in the Finance Ministry. Tobacco industry stakeholders have served as members on various national economic development committees and projects where they established links with those in positions of power. Research conducted in low and middle income countries suggest that a ministry of finance is likely to support the industry because of the tax revenues it generates, and so the industry is likely to accrue substantial political power. Other ministries, such as health, are likely to oppose the tobacco industry for the fatalities, disabilities and illness-related costs that it produces.
The Minister of Heath (Maithripala Sirisena at the time) notified the enforcement of 80% of the pictorial warnings in cigarette packs issuing an extraordinary gazette on 8 August 2012. This is a privilege given to the Minister from the NATA Act 2006. Contesting this gazette notification, Ceylon Tobacco Company PLC challenged the Health Minister and sought an interim order to stop the implementation of the regulation until their substantive challenge was concluded in Court. The Court found that the regulation was sufficiently clear for implementation, considering the Government’s interest of promoting public health, particularly in in view of its obligations under the FCTC. However, the Court reduced the percentage cover of the PHWs to a maximum of 60%. It is said that national tobacco industry business stakeholders supported by TTCs, significantly influenced key decision-makers within Government to avert tobacco control regulations and delay the PHWs coming into force until 2015.
President and Minister of Health as tobacco control policy champions
The political climate has significantly changed following the election of President Sirisena from the previous presidency’s focus on tobacco control policy formulation to one of policy implementation. On election, President Sirisena disclosed the difficulties he had encountered as Minister of Health during the Rajapaksa presidency when trying to implement tobacco legislation.
A keynote speaker at the Conference of Parties to the WHO FCTC in November 2016, President Sirisena described the tobacco industry’s interference in government policy-making and how he now supports the Minister of Health Dr. Rajitha Senaratne to withstand undue pressure from the tobacco industry. They have ensured that tobacco control remains vital, underpinned by their belief in protecting public health. Their keen interest in policy implementation and their combined political strength are catalysts for a new landscape in tobacco control policies in Sri Lanka.
New legislation was introduced recently to ensure that 80% of the surface of the cigarette packet is covered with PHWs. Despite difficulties with Finance Ministry officials, tax on tobacco was also increased to 90%. Additionally, the Health Minister has shown a keen interest in banning the sale of loose tobacco, another step to reduce the demand for tobacco.
President Sirisena and Dr. Rajitha Senaratne can be described as tobacco control policy champions as they take extraordinary interest and effort in the implementation of tobacco control policies. Analysis of tobacco control policies situated in the history of Sri Lanka suggests that legitimisation and implementation of technical and scientific advice on tobacco control is subject to the interests of powerful political stakeholders.
Considering the current favourable political climate, there are many opportunities for international experts, scientists, NGOs and other interested parties to further their agenda on tobacco control. Although the impact of the recently implemented polices may not show us any significant outcomes in the short-term, the public health outcomes in the long term should be immense.
[Dr. Nimesh Samarasinghe (PhD, MSc, BSc (Hons), DipHE) has extenstive experience working in the British National Health Service in clinical, managerial and commissioning roles. He is currently working as a Consultant, assisting the State of Qatar to develop and modernise their health services.]