Objective To produce a tool to assess and guide sustainability of national tobacco control programmes.
Method A two-stage process adapting the Delphi and Nominal group techniques. A series of indicators of tobacco control sustainability were identified in grantee/country advisor reports to The International Union Against Tuberculosis and Lung Disease under the Bloomberg Initiative to Reduce Tobacco Control (2007–2015). Focus groups and key informant interviews in seven low and middle-income countries (52 government and civil society participants) provided consensus ratings of the indicators’ relative importance. Data were reviewed and the indicators were accorded relative weightings to produce the ‘Index of Tobacco Control Sustainability’ (ITCS).
Results All 31 indicators were considered ‘Critical’ or ‘Important’ by the great majority of participants. There was consensus that a tool to measure progress towards tobacco control sustainability was important. The most critical indicators related to financial policies and allocations, a national law, a dedicated national tobacco control unit and civil society tobacco control network, a national policy against tobacco industry ‘Corporate Social Responsibility’ (CSR), national mortality and morbidity data, and national policy evaluation mechanisms.
Conclusions The 31 indicators were agreed to be ‘critical’ or ‘important’ factors for tobacco control sustainability. The Index comprises the weighted indicators as a tool to identify aspects of national tobacco control programmes requiring further development to augment their sustainability and to measure and compare progress over time. The next step is to apply the ITCS and produce tobacco control sustainability assessments.
- Global health
- Low/Middle income country
Statistics from Altmetric.com
The year 2015 marks the 10th anniversary of the WHO Framework Convention on Tobacco Control (WHO FCTC). Significant progress has been made1 ,2; nonetheless, tobacco remains the world's major preventable cause of death and the largest risk factor for non-communicable diseases (NCDs). This burden is particularly great in low and middle-income countries (LMICs). Daily smokers increased by 609 million in middle-income countries from 1980 to 2013 and two-thirds of all tobacco deaths are in LMICs.3
The WHO ‘MPOWER’ package of six evidence-based strategies: ‘Monitor’, ‘Protect’, ‘Offer’, ‘Warn’, ‘Enforce’ and ‘Raise’ was developed to assist global efforts to apply the WHO FCTC and address the tobacco epidemic.4 Forty per cent of the world's population lives in countries with at least one MPOWER measure in place at the highest level, and a number of populous countries have enacted four or more of the measures. While this is a major achievement, the implementation level in some countries is an issue and almost two-thirds of the global population does not yet have the most effective level of protection under one measure.2 This mixed picture is similar regarding capacity and infrastructure for tobacco control. The landscape has evolved markedly during the FCTC period. Many governments have developed national programmes and a dedicated unit to lead and coordinate tobacco control, and the number and range of civil society organisations working on tobacco control, and their activity, has increased substantially5 ,6 ,7. The technical and management capacity of this workforce has also developed.5 ,6 ,8 ,9
Governments that have passed strong tobacco control legislation face pressure from the tobacco industry to dilute their policy and implementation and expend time and resources rebutting legal challenges.10 Strengthened government codes of conduct based on FCTC Article 5.3 are necessary.11 Cross-governmental tobacco control coordination mechanisms are not yet common practice and are essential to build shared understanding and cooperation between government departments, address conflicts that can stymie policy progress and facilitate cross-government action. Governments require further support to develop their capacity, programmes, policies and cross-governmental linkages in order to effectively address tobacco use and sustain this effort.
National-level funding for tobacco control is a further obstacle in both high-income countries (HIC) and LMICs. It has been suggested that some HICs that have passed strong legislation have then reduced tobacco control budgets based on a ‘job done’ or are failing to maintain programme funding at an effective level,12 whereas the LMIC challenge is maintaining and accelerating tobacco control progress in the context of myriad spending priorities.13
Increased tobacco taxation and tax loophole reform has been consistently demonstrated to have a powerful effect on tobacco use and promoted as the leading MPOWER strategy.14–16 The sixth Conference of the Parties17 approved tobacco taxation and price guidelines including the use of revenues to finance tobacco control.5 This latter point is significant for funding and sustaining tobacco control, yet only 23 of the 180 Parties to the Convention have so far used tobacco tax increases and reforms to create sustainable funding mechanisms for health programmes.18
Many countries require further development on several aspects of tobacco control: policy strength, infrastructure, capacity and resourcing, in order to accelerate progress to reduce tobacco prevalence, mortality and morbidity as required by the UN Sustainable Development Goals (SDGs). WHO FCTC is cited as a ‘means of implementation’ to achieve the overall health goal (SDG 3) and a target on NCDs.19 For tobacco control to contribute in this way, there is an immediate need to ensure that it can be sustained to deliver on these medium and longer term outcomes. This issue has been prioritised for the Conference of Parties 2016 agenda,15 and the sustainability of tobacco control is the focus of this paper.
At a global level, the WHO FCTC reporting process20 and GTSS surveys21 measure an extensive range of aspects of tobacco control progress at regular intervals, providing an overview of tobacco use prevalence and consumption, policy adoption and implementation effectiveness. While reporting on progress can be strengthened,15 a system of data collection and assessment is in place. The concept of tobacco control sustainability is interpreted here as whether the key policies and infrastructure (such as personnel, resources, collaborative mechanisms) that are required to undertake and maintain effective tobacco control over the medium/long term are in place. These measures must be effective in order to deliver progress; however, systematic progress measurement and reporting on these already exist.20 ,21 What is lacking is a means to identify whether countries have the key building blocks in place to sustain effective tobacco control measures and to enable governments and civil society organisations to monitor progress in developing the sustainability of their national tobacco control programmes.
Other sectors, notably the environmental sector, have developed sustainability measurement tools. One example is the Environmental Performance Index (EPI),22 a method for quantifying and numerically marking a country’'s environmental performance as regards sustainability. The 2014 EPI ranks 178 countries on 20 indicators in 9 categories to track performance and progress on two broad policy objectives, environmental health and ecosystem vitality, and facilitates cross-country comparisons.
As regards tobacco control, Stillman et al23 developed a ‘Strength of Tobacco Control Index’ (SOTC) to measure the effects of the ‘American Stop Smoking Intervention Study’. The SOTC measured tobacco control programme activity, capacity and resources and their effectiveness across US States. This tool was developed in a High-Income setting in 2003, prior to the WHO FCTC and the major shifts in tobacco control policy progress and national programme development that ensued, and instigated significant development in LMICs. This paper reports on the process to develop a new tool, building on the SOTC concept and drawing from the tools for environmental sustainability that enable cross-country comparisons. The ‘Index of Tobacco Control Sustainability’ (ITCS) has been designed to be relevant to the tobacco control landscape more than a decade following FCTC. In this context, structures for tobacco control progress/performance assessment exist20 ,21; and countries of all income levels are seeking to strengthen and maintain tobacco control efforts to address NCDs and the SDGs in a challenging economic climate.
The method used adapts the Delphi and the Nominal group techniques.24 This is similar to methods used to develop measurement tools on other tobacco control topics, such as the Tobacco Control Scale25 and the SEATCA Tobacco Industry Interference Index.26 In stage one, experienced tobacco control advisors reviewed grant and country programme reports (2007–2015) submitted to The International Union Against Tuberculosis and Lung Disease under the Bloomberg Initiative to Reduce Tobacco Use Grants Programme.27 In these reports, grantees and advisors had provided specific information regarding the ‘sustainability’ of tobacco control in the particular country. The data were used to identify themes to reflect the range of aspects of tobacco control sustainability and were synthesised into seven groups of ‘Indicators of tobacco control sustainability’. The 31 ITCS indicators differ from those in the SOTC as they were designed to reflect whether key policies, frameworks, resources and aspects of capacity were in place, not to assess their effectiveness, while the ITCS indicators were simplified to provide comparative national data from a wide range of countries.
Stage two enabled individuals with tobacco control experience to provide feedback on the proposed indicators and contribute to a consensus view of their relative importance. Focus groups (five countries) and a series of key informant interviews (two countries) were organised in seven LMICs. Countries (China, Chad, Indonesia, Mexico, Bangladesh, Georgia and Pakistan) were selected to represent a range of WHO global regions from countries where The Union supports tobacco control and where the topic of sustainability has featured in discussions. Participants included governmental and civil society participants (6–8 per country, total n=52). Discussions were conducted in local languages. At the beginning of each focus group/interview series, facilitators explained the ITCS concept and the individual indicators and facilitated discussion on whether the group collectively rated indicators ‘'not important’, ‘important’ or ‘critical’ for tobacco control sustainability. Groups were invited to identify any indicators they felt were irrelevant for their country, or any relevant indicators that were absent. Facilitators noted feedback and provided translated written data.
ITCS indicator weighting and scoring system
Data were analysed and checked with facilitators and the findings from the different countries were triangulated with the initial Union report data. Table 1 shows the participants' ratings of importance by country and the groupings by relative importance in three categories:
‘Acutely Critical’: indicators rated as critical by the majority of countries;
‘Critical’: approximately 50% of countries rated the indicators as ‘critical’ and approximately 50% as ‘important’;
‘Important’: indicators rated by the majority of countries as ‘important.’
The three groupings and the number of countries that accorded the ratings to each indicator within these groups were used to initially allocate weighted scores. Indicators in the ‘Acutely Critical’ grouping received a higher weighting than ‘Critical’, and these were weighted more than the indicators rated as ‘Important’. Individual indicators within the groupings were allocated relative weightings based on the number of group ratings of that level. Thus, the indicator ‘National TC Budget (annual)’ received seven country ratings of ‘Critical’, and so this was weighted higher than the indicator ‘Tobacco taxation increases faster than Inflation plus Gross Domestic Product (GDP) growth’ that had six ‘Critical’ ratings. These initial weightings were then assessed to consider the overall implications from a technical perspective and make any adjustments if a clear rationale was identified.
The weighted scores for each indicator allow a country's tobacco control programme to be rated with a total score to reflect its progress towards developing tobacco control sustainability and enable comparison over time and with other countries. A threshold score for a country's tobacco control to be considered sustainable will be set after applying the ITCS in a sample of countries. The finalised Index is presented in table 2.
The ITCS development process engaged 52 participants including government officials and non-governmental organisation representatives in seven LMICs, spanning all the WHO regions. This sample was intended to represent a cross-section of individuals engaged in tobacco control across a range of countries. Nonetheless, it is possible that alternative views might be found in countries beyond the sample.
Focus groups and interviews were facilitated by individuals known to the participants within the national tobacco control community, and in some cases facilitators were advisors and overseers of participants' funded projects. Although this might have influenced participants' feedback, this was considered less significant in a broad national policy discussion than if it related to their own projects and outcomes. Facilitators encouraged participants to express their own views on national sustainability priorities.
The methodology, combining aspects of the Delphi and Nominal group techniques, was selected to identify consensus opinions on the relative importance of the indicators across a range of countries. The indicator ranking and allocation of relative weightings entailed technical judgement and interpretation of the consensus findings. While the indicators could be ranked and weighted in alternative ways, the method and rationale employed were agreed on by experts with significant tobacco control experience across a range of countries, and have been presented to enable readers to understand how the ITCS was produced.
The indicators do not assess whether the measures are effective but focus on their presence/absence. It is agreed that a law or policy that is poorly implemented or a unit that is understaffed will not deliver effective tobacco control. Not specifying threshold measures for many of the indicators is not meant to imply that effectiveness is unimportant. As previously discussed, a system already exists to assess national progress and whether policies and structures are effective. The value of this Index is precisely that it offers a means for countries to understand and focus on putting in place the measures essential to sustain national tobacco control over the medium/long term and address the scale of the tobacco problem. National circumstances vary considerably between countries, not just between regions or HICs and LMICs, and thus it would be problematic to specify a required level for many indicators for which a global standard does not exist. Where a global ‘gold standard’ has been established such as on tobacco taxation28 and minimum spend,29 these thresholds have been included. The result is a standardised tool that can be easily applied across countries, allowing also for cross-country comparison that in itself is an important catalyst of progress.
All 31 of the selected indicators were rated either as ‘Critical’ or ‘Important’ by a sizeable majority of the focus groups (table 1). The 13 indicators rated ‘Critical’ by a clear majority of groups related to financial policies and allocations (a national tobacco control budget was the only indicator universally rated as ‘Critical’), tobacco taxation >70% of the Retail Sales Price, having a national law, a dedicated national Tobacco Control Unit and a civil society tobacco control network, a national policy against tobacco industry ‘Corporate Social Responsibility’ (CSR), national mortality and morbidity data, and national and policy evaluation mechanisms. These indicators were accordingly given greater weighting in the ITCS.
Thirteen indicators were rated either ‘Critical’ or ‘Important’ by approximately 50% of groups. These were: a national tobacco control strategy, tobacco control and NCDs included in national policy and national development plans, a national focal point and human resource for implementation, an intergovernmental coordination mechanism, a capacity-building plan for tobacco control personnel, tobacco control included in ‘development assistance’, WHO FCTC article 5.3 measures to counteract the tobacco industry, collection of morbidity, mortality and socioeconomic data, and national evaluation mechanisms. These indicators were accorded weightings lower than those that a majority identified as ‘Critical’, but higher than the indicators where a majority rated them ‘Important’.
Five Indicators rated ‘Important’ by a clear majority of groups were: >4 MPOWER policies in place, national tobacco control advisory committee, capacity-building for wider personnel and capacity building plans on evaluation. These indicators were weighted with lower values than the ‘Critical’ indicators and the indicators that were approximately 50% ‘Critical’, 50% ‘Important’.
Only four indicators received a rating of ‘Not important’ and these were by a single national group in each case while rated by most other groups as ‘Important’ and in some cases as ‘Critical’. The perceived lower importance of these indicators in the four instances appears to be explained either by a group’'s particular interpretation of the indicator and/or by specific national circumstances, as explained in the information recorded by facilitators. For example, the Chad group believed that mass media would automatically be included if the indicator ‘>4 MPOWER measures’ was in place and so rated mass media funding as ‘Not important’, considering this a duplication. It was reported that the China group of participants decided to rate ‘>4 MPOWER measures’ as ‘Not important’ because their national evaluation had recently shown that tobacco industry interference had stymied the impact of policy measures that had been enacted. Concomitantly, the China group rated measures on article 5.3 for government and against tobacco industry ‘CSR’ as ‘Critical’.
In the general discussion, the groups universally suggested that a tool to measure progress towards tobacco control sustainability would be valuable. One group proposed that the sustainability assessment would be best achieved by an independent ‘third-party’.
The concept of a tool to help assess and guide development of tobacco control sustainability received universal support from government and civil society participants in the seven countries. The context of increasing NCD prevalence and the need to deliver on the new SDG3 partly explain this. The issue of adequate, sustained funding is an important further reason, and is high on the agenda of the tobacco control workforce and supporters in many countries, owing to reduced budget allocations in some HICs31 and the degree of reliance on external resources in many LMICs.14
Developing the ‘Index of Tobacco Control Sustainability’ is a step towards addressing this need, providing a means to assess whether countries have the policies, structures, resources and capacities in place to sustain effective tobacco control measures and to monitor and guide progress. The ITCS focuses specifically on the essential ‘building blocks’ to sustain national tobacco control programmes and is intended as a complementary tool to the established mechanisms that assess whether tobacco control is operating effectively to reduce tobacco consumption and prevalence.
A high degree of consensus was found within and between countries on the relevance of the 31 indicators. This confirmed that stage one of the methodology had successfully identified key themes regarding tobacco control sustainability. There was substantial consensus also regarding the indicators' relative priority, with the vast majority of groups rating each indicator as ‘critical’ or ‘important’, despite encouragement to critique the indicators and identify any that were irrelevant or missing. The few cases where groups indicated that a specific single indicator was not important (four of the total 217 ratings) suggests that groups were not averse to categorising indicators as unimportant if they believed this was appropriate.
In developing the ITCS, indicators were allocated weighted scores to provide countries with an overall score to indicate how far they were on the continuum towards developing sustainable tobacco control, and to enable progress monitoring and comparison with other countries. The ratings of relative importance by countries were the leading factor in the weighting process, although these were also reviewed from a technical perspective. Weightings were agreed on the basis of relative importance ratings for all indicators, with one exception. This was ‘>4 MPOWER policies in place’, which was rated ‘Important’ by a majority of countries, yet few rated it ‘Critical’, and one group rated it ‘Not Important’, explaining that the tobacco industry interference had undermined their national policies. Taking an overview perspective of all indicator ratings, feedback, and the broader evidence on what will reduce tobacco consumption, the study team decided that this indicator should be rated higher than other indicators in the ITCS and also be a ‘pre-requisite’ factor, without which countries could not be considered to have achieved sustainability.
The factors identified as ‘critical’ provide an insight into what are perceived as essential components of a sustainable national tobacco control programme. Financial policies and budgetary allocations to sustain programmes were consistently rated the highest. Foremost was an allocated national budget, reflecting an issue highlighted in the research literature and the WHO FCTC recommendations as a priority.5 ,32 ,33 High ratings were accorded to tobacco taxation being FCTC-compliant and health promotion fund development as per the COP recommendation,34 suggesting that these are widely seen as appropriate mechanisms to deliver the required funding. When the focus groups were conducted, the indicator for the tobacco taxation level as a percentage of Retail Sales Price was set as >70%; however, in the subsequently released WHO report,2 the recommended level had been adjusted to >75%. It was decided that the new optimal level should be the one used in the finalised ITCS. Several groups suggested that an explanatory note for the indicator ‘Tobacco taxation increases faster than -inflation plus GDP growth-’ would assist people who had limited economic knowledge. This appears to reflect a particular need for capacity building on tobacco economics.3 It is intended that the Index will be applied as a facilitated process, supplemented by table 3 that briefly defines each indicator and its contribution to tobacco control sustainability.
The other indicators identified by consensus as ‘Critical’ related to key government infrastructure factors, including national legislation, central coordinating infrastructure and personnel, policies to address tobacco industry interference, national data on morbidity, mortality and socioeconomic aspects of tobacco. The prioritisation of these factors reflects the data collected in the WHO ‘Reports on the Tobacco Epidemic’ series35 and suggests that personnel working in tobacco control across a range of countries consider these as critical to undertake effective tobacco control in the present, as well as to do so on a sustainable basis until the tobacco threat has been addressed.
All groups agreed that active civil society involvement was a vital complement to the government infrastructure in terms of sustaining tobacco control. This may in part be a function of the study sample composition, which was purposively composed half of government and half of civil society representatives; nonetheless, it was a consensus view across countries.36 ,37 A clear majority of groups rated two indicators as ‘critical’ and these reflect two key roles for which the contribution of civil society to tobacco control has been noted. First, an ‘internal’ role—‘Civil society having representation on national tobacco control advisory committees’, whereby civil society has a formal ‘seat at the table’ to contribute and add an alternative perspective to decision-making and guide policymakers in areas where civil society has significant practical experience.38 ,39 Second, an ‘external’ role—‘a civil society tobacco control network’, a mechanism for civil society to plan and coordinate activity and provide a recognised, visible forum to raise issues and concerns.40 ,41
The ITCS will be used to provide an objective assessment of national tobacco control sustainability in a country (and relative to other countries in its region/of similar profile), and to highlight specific areas requiring development. The Union, with its offices across the globe, will undertake assessments using the ITCS and disseminate a report to be shared with all stakeholders. It is anticipated that government and wider stakeholders can use the findings to guide their policy, programme and advocacy efforts.
A consensus of stakeholder groups in seven countries categorised 31 aspects of tobacco control sustainability as ‘critical’ or ‘important’. These were used to develop the ITCS as a tool to assess, monitor and compare a country’'s overall progress towards tobacco control sustainability and to identify specific areas requiring further work. The next step is to work with national stakeholders to apply the Index in a range of countries and use the results to set a threshold score of sustainability. The Index can then be widely used to undertake tobacco sustainability assessments and provide countries with feedback to guide the development of national tobacco control.
What this paper adds
The importance of tobacco control sustainability (ITCS) has been widely discussed in the post-Framework Convention on Tobacco Control period and sustainability measurement tools have been developed by other sectors, yet limited work had been done to identify the components of tobacco control sustainability and to enable countries to assess and monitor progress on this. This study identified 31 indicators that were agreed by a consensus of participants across seven countries as ‘critical’ or ‘important’ factors for tobacco control sustainability. These data were used to develop the ITCS, a tool to assess the sustainability of national tobacco control programmes and identify aspects requiring further development.
The authors extend their thanks to Anne Jones OAM, Dr Jorge Laucirica, Dr Gan Quan, Fouad Aslam, Dr Tara Singh Bam, Ishrat Chowdhury, Daouda Adam and Dr Jean Tesche of The International Union Against Tuberculosis and Lung Disease (The Union) and Dr Nuka Magdakelidze of the Government of Georgia for their assistance in coordinating and facilitating the country Focus Groups, and to the Focus Group participants in the seven countries. We also thank Richard Parker, Senior Statistician, University of Edinburgh, Centre for Population Health Sciences, for advice; and Mithun Nair (The Union). The Union's work on tobacco control is supported by ‘The Bloomberg Initiative to Reduce Tobacco Use’.
Contributors Dr Angela Jackson-Morris and Dr Ehsan Latif contributed equally to this paper.
Funding Bloomberg Philanthropies.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.