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Assessment of short reports using a human rights-based approach to tobacco control to the Commitee on Economics, Cultural and Social Rights
  1. Carolyn Dresler1,
  2. Kirsten Henry2,
  3. John Loftus3,
  4. Harry Lando4
  1. 1 Human Rights and Tobacco Control Network, Rockville, Maryland, USA
  2. 2 School of Public Health, Humphrey School of Public Affairs University of Minnesota, Minneapolis, Minnesota, USA
  3. 3 University of Minnesota Minneapolis, Minneapolis, Minnesota, USA
  4. 4 Division of Epidemiology and Community Health School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
  1. Correspondence to Dr Carolyn Dresler, Human Rights and Tobacco Control Network,4419 Renn St,Rockville, MD 20853 United states; carolyn_dresler{at}ksg03.harvard.edu

Abstract

Background The health impact of tobacco use remains a major global public health concern and a human rights issue. The Human Rights and Tobacco Control Network (HRTCN) was established to increase the visibility of tobacco as a human rights issue. HRTCN submitted short reports to the UN Committee on Economic Social and Cultural Rights evaluating individual nations' tobacco control policies and offering recommendations.

Methods HRTCN reviewed Concluding Observations documents for nations for which the HRTCN submitted reports. If tobacco was mentioned in the Concluding Observations through acknowledging the Framework Convention on Tobacco Control ratification, policy changes or discussing tobacco in the recommendations, this was scored as a positive finding. HRTCN also reviewed Concluding Observations for nations for which HRTCN did not submit reports as a comparison.

Results Thirty-eight HRTCN reports were submitted and tobacco was mentioned in Concluding Observations for 11 nations for a rate of 28.9%. In a comparison set of Concluding Observations (n=59), 7% had comments or recommendations relative to tobacco.

Conclusions This was not a controlled study and the 28.9% ’success rate' for impacting the Concluding Observations, although encouraging, is less than optimal—and leaves room for improvement. The higher rate of tobacco mentions for the cases where the HRTCN short reports were submitted provides preliminary indications that the short reports may have potential to increase the state focus on tobacco control. Future work will seek to improve the design and scope of the reports, and the specificity of the background information and recommendations offered.

  • human rights
  • tobacco control evaluation
  • FCTC evaluation
  • CESCR

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Background

Human rights-based approaches may advance the aims of understanding and addressing global economic, public health and social justice challenges, including tobacco control.1 The Framework Convention on Tobacco Control (FCTC) exists accordingly within a human rights-based framework. Building from the values held in other United Nations institutions and documents comprising the International Bill of Human Rights, including the Universal Declaration of Human Rights (UDHR), the International Covenant on Economic, Social and Cultural Rights (ICESCR), the International Covenant on Civil and Political Rights (ICCPR), the Convention on the Elimination on All Forms of Discrimination Against Women (CEDAW), and Convention on the Rights of the Child (CRC), the FCTC affirms aspects of human rights relevant in a tobacco control context including the right to health, a safe living and working environment and the rights of children, women and minority groups.

The right to health is broadly defined in the above-mentioned documents. The WHO constitution asserts that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition.”2 Article 25 of the UDHR establishes for each person “the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”3 Together these interpretations of the human right to health allow for interpretation and extension in order to establish a progressive standard of health or living. Thus, within a human rights-based approach to tobacco control, this includes concerns pertaining to environmental or occupational safety (second-hand smoke or tobacco cultivation and processing hazards), access to health education and information (including freedom from inaccurate or manipulative advertising) and access to healthcare services. As mentioned above, human rights notions regarding children’s rights relating to advertising and labour issues, and the rights of women and minority groups regarding health disparities, also lend support to a comprehensive framework (See CRC, CEDAW and Convention on the Elimination of Racial Discrimination for more rights that are impacted).4–6 Finally, health outcomes of tobacco use in specific populations provide metrics to create and evaluate evidence-based interventions.

There is a strong argument for a human right to tobacco control policy specifically, both from a rights-based legal and ethical perspective as well as from an empirical perspective. Cabrera and Mendoza argue that if states are to uphold the right to health for their populations, they have an obligation to stop the spread and reduce the prevalence of the tobacco epidemic.7 The data to demonstrate the health burden of tobacco use are overwhelming, as is the knowledge of the diversity of tobacco-related harms and hazards. The prevalence of tobacco use has largely shifted towards more marginalised populations, and the occupational safety concerns resulting from the tobacco industry’s manipulative actions toward women, children and marginalised groups in the sale and marketing of tobacco are well established.8 9 Dresler and Marks maintain that there is also a logical argument for the human right to tobacco control. Tobacco is manufactured into a cigarette product that negatively affects one’s health through addiction to a known harmful substance, lethal when consumed as intended by tobacco corporations.1 Furthermore, advertising and misinformation campaigns, and interference in public health policy-making, serve to distort consumer understanding about the dangers of the product. State ownership of tobacco production, or the ‘Smoker’s Paradise’ tourism advertising campaign in Mexico are examples of a conflict of interest in reducing tobacco use, and therefore a failure to uphold human rights.7 From an intervention standpoint, the locus of tobacco hazards has been spread throughout the supply chain, and has come to include primarily issues that require state intervention and, increasingly, solutions crossing state or national boundaries. States and intergovernmental organisations therefore have ethical and legal obligations to develop effective policy aimed at ending the tobacco epidemic.

The ICESCR, adopted by the UN along with the ICCPR in 1966, developed the human rights that were ‘declared’ in the UDHR into more directed and binding obligations by the party states: “Article 12. 1. The states parties to the present Covenant recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”10 This obligation for states to promote and protect the human right to health as it pertains to tobacco is mentioned in the General Comment 14 to the ICESCR Article 12.11 The Committee on Economic, Social and Cultural Rights (CESCR) was developed to monitor implementation of the (ICESCR) by its states parties. The CESCR reviews reports from state parties and civil society organisations on the status of ICESCR implementation, and provides feedback and recommendations for further policy development. This mechanism provides an important source of accountability, as well as a platform for civil society organisations and for states party to the ICESCR and their policies in the protection of rights pertaining to health. States that are party to the ICESCR are legally bound to progressively implement the treaty, and the CESCR’s review and recommendations are to be considered seriously by the state. Further remedies could be sought in human rights courts, for example, in India, the right to clean air was adjudicated by the Indian Supreme Court in 2001.12

Civil society organisations play a critical role in the CESCR review process, primarily through the submission of ‘shadow reports’—meant to ‘shadow’ the states parties’ periodic required reports. ‘A guide to tobacco-related shadow reporting before United Nations human rights bodies’ argues that shadow reports are useful for holding states accountable for putting forth effective tobacco control policy and, importantly, also for ‘strengthening the connection between the WHO’s FCTC and human rights obligations.”13 Overall, shadow reports provide to the CESCR the valuable perspective of human rights and social justice-focused activists or organisations, which can provide information—observations or statistics—that might otherwise be concealed or omitted in state reports.

The Human Rights and Tobacco Control Network (HRTCN) is one such civil society organisation that submits reports, focusing on Article 12, to the CESCR in order to highlight the issue of tobacco control and to champion a human rights-based approach to tobacco control policy, acting as a rights-defending organisation to the CESCR.14 Beginning in 2010, HRTCN has submitted a short form of shadow report—a ‘short report’—briefly analysing tobacco policy and offering recommendations based on MPOWER policies for countries around the world.15 Short reports (SRs) are a concise, one-page summary containing one to three paragraphs of background information, including positives and negatives of a state’s tobacco control policy, and providing brief recommendations for improvements tailored to the state’s unique circumstances. Background information, prevalence of use, status of FCTC ratification and tobacco policies were usually gleaned from internet searches of country, region, national and international websites. Such sources were referenced in the SR. Attempts were undertaken through personal connections of the senior authors (CD, HL) to develop the SR with in-country experts, but this was often difficult. It is thought that SRs may be as effective an approach as longer shadow reports, and that through their concise and direct nature, they provide a means of highlighting and demonstrating evidence supporting tobacco control and human rights to the CESCR. The present study is a preliminary analysis of using these SRs in highlighting tobacco as an issue in CESCR recommendations.

Methods

HRTCN began submitting SRs with Session 45 PS (presessional) in 2010. The HRTCN submitted SRs for nations included in sessions 45–56. Sessions 45–56 included a total of 76 nations, and HRTCN submitted SRs for 38 countries. State Reports, other submitted materials from non-governmental organisations and Concluding Observations documents for all countries were reviewed for the sessions of the CESCR from November 2008 to February 2016 and included Session numbers 41–56. These reviews identified those conclusions which included some mention or recommendation about tobacco control policy. If tobacco or tobacco control was mentioned anywhere within the Concluding Observations in the form of acknowledging FCTC ratification, praising or criticising specific policy changes or otherwise discussing tobacco, these comments were then compared with the SR recommendations. If the comments were analogous to the SR recommendations and distinct from any tobacco-related aspects of the state report, this was considered a positive result of the SR submission. Positive results were further differentiated into two categories: a mention of tobacco policy in the ‘Positive Aspects’ section (such as recognition of ratification of the FCTC) or recommendations for changes to tobacco policy in the ‘Principal subjects for concern and recommendations’ section. The Concluding Observations were also reviewed for nations for which HRTCN did not submit reports as a comparison. The frequency of a positive result was determined as a mention of tobacco policy, in the Concluding Observations for nations for which the HRTCN did and did not submit a short report. Our ‘case’ group therefore was those nations for which HRTCN submitted a report while the comparison group was the set of nations which did not receive an HRTCN report.

Results

CESCR sessions 41—56 were reviewed. Table 1 shows the results of our search for mentions of tobacco in all of the CESCR Sessions including the ‘Concluding Observations’ documents for the nations for the time period for which HRTCN SRs were submitted (n=38). Seven country SRs were submitted by HRTCN but not listed on the CESCR website; however, their receipt and review by the CESCR was confirmed by the CESCR Secretariat (private communication). Eleven countries for which HRTCN submitted SRs received a mention of tobacco in the Concluding Observations from the CESCR (Argentina, Armenia, Bulgaria, Cameroon, Indonesia, Jamaica, Lithuania, New Zealand, Slovakia, Turkmenistan, Uzbekistan). The 11 mentions of tobacco in the Concluding Observations that correlated with the HRTCN SRs is suggestive of an influence rate of approximately 28.9% (11/38).

Table 1

38 Countries with Human Rights and Tobacco Control Network short reports submitted to The Committee on Economic, Social, and Cultural Rights (CESCR), Sessions 45PS-56 (November 2010–September 2015) (*denotes positive comment and/or ** recommendations from CESCR Concluding Observations)

Five of these were recognitions of positive changes to tobacco policies, listed under the ‘Positive Aspects’ section (Armenia, Lithuania, Bulgaria, Jamaica and Turkmenistan). The remaining six mentions were recommendations (Indonesia, Uzbekistan, Argentina, Cameroon, New Zealand and Slovakia). In the case of Argentina, in addition to the HRTCN short report, a more comprehensive shadow report discussing the health and economic costs of tobacco and tobacco control policy was submitted to the CESCR from the O’Neill Institute, La Fundación InterAmericana del Corazón Argentina and La Fundación Para el Desarrollo de Políticas Sustentables.16 No other shadow reports or reports addressing other aspects of tobacco were submitted for Sessions 46–56. Table 2 lists the countries in the comparison group (Sessions 46–56, n=34) and earlier Sessions (41–45, n=25). Four nations received mentions of tobacco control in the Concluding Observations for a positive-mention rate of approximately 7% (4/59) (Kazakhstan and Mauritius (Session 44), Belarus (Session 51) and Kyrgyzstan (Session 55)). A strong shadow report on tobacco and labour issues in Kazakhstan from Human Rights Watch was submitted in Session 44. Mauritius, Belarus and Kyrgyzstan had mentioned some tobacco or tobacco control activity (such as child labour measures) in its state report, CESCR asked for further information about the topic (except for Kyrgyzstan). These concerns were then evident in the final Concluding Observations from the CESCR.

Table 2

Comparison countries: 25 countries reviewed by The Committee on Economic, Social and Cultural Rights (CESCR) prior to the start of Short reports (SR) from the Human Rights and Tobacco Control Network (HRTCN) during sessions 41–45 (November 2008–November 2010 and 34 countries reviewed by CESCR during the time period that HRTCN submitted SR (November 2010–September 2015, Sessions 45–56). ** denotes recommendations from CESCR Concluding Observations

To further assess the possible impact of the HRTCN short reports, we cross-referenced the background information provided in the SRs and the suggested recommendations for those nations. Excerpts from the recommendations given by the CESCR are included in online supplementary table 1 . In all cases, the Committee tended to expand the specific recommendations offered in the HRTCN SRs to more broad or general statements. In the two cases of Indonesia and Cameroon, the recommendations of HRTCN were incorporated into the Concluding Observations directly. Meanwhile, in the Concluding Observations for Uzbekistan, the CESCR discussed the need for tobacco control and awareness more broadly along with alcohol and other substance use issues. The Committee did include tobacco control recommendations in the Concluding Observations for Argentina which accord with the recommendations provided by the comprehensive shadow report submitted by the O’Neill Institute and the HRTCN. Therefore, it is not clear if the mention in the Concluding Observations are a result of the HRTCN short report, the O’Neill Institute report or a result of both.

Supplementary file 1

Regarding mentions under the ‘Positive Aspects’ section in the ‘Concluding Observations’ documents, which included Turkmenistan, Bulgaria, Armenia and Lithuania, all but Bulgaria were positive commendations for ratification of the WHO FCTC. The ‘Concluding Observation’ document for Bulgaria, however, included a mention of amendments to Bulgaria’s Health Act, passed in 2012, which was also highlighted in the body of the HRTCN short report: “The Committee takes note with appreciation of the state party’s efforts to promote the implementation of economic, social and cultural rights, which have included:[…](c). The amendments introduced to the Health Act in 2012 to prohibit smoking indoors in public places and certain outdoor places’.

Discussion

The results of this initial assessment suggest a potential for HRTCN SRs to influence the CESCR to include tobacco control in their assessment of party states. With limited sample sizes, however, these results must be considered preliminary. Nonetheless we note a ‘success rate’ for those countries which received SRs approximately four times the ‘success rate’ for those that did not receive a report. In most cases, the content of the recommendations or other tobacco mentions included in the Concluding Observations documents closely reflected the information included in the submitted HRTCN SR. We only found one shadow report during our intervention time period besides the HRTCN SRs submitted to the CESCR that mentioned the issue of tobacco control, a more comprehensive shadow report for Argentina (Session 47). These observations together suggest that SRs may positively influence the CESCR to prioritise tobacco issues in their country assessments. It will be important to continue this impact assessment as the number of submitted SRs grows and therefore sample sizes increase.

Many factors could influence the likelihood of tobacco being mentioned in the CESCR’s assessments and Concluding Observations. These include but are not limited to: other submitted shadow reports, current political climate, tobacco control presentations to the CESCR, increased inclusion of tobacco related reporting in state reports and other competing issues and topics in a given country. Considering that the Concluding Observations documents are relatively condensed, it is possible that other, very urgent human or civil rights violations or issues would take precedence over tobacco control. In addition, for countries which have less-developed healthcare or public health infrastructure overall, it could seem less productive for the Committee to focus on tobacco control rather than discussing basic development of health infrastructure which would allow the means to better address tobacco control and other priorities pertaining to health. However, tobacco control is critically important given the tremendous harms of tobacco and the tobacco industry’s highly globalised, rich, powerful oligopoly that targets low/middle-income nations.17 18 Few nations can afford the healthcare cost for treating tobacco-caused disease. Focusing on tobacco control immediately, along with other pressing issues, is necessary in order to avert the spread of this epidemic. More to the point, the actions of tobacco companies in their participation and interference in the political and economic systems of developing nations, and widespread cases of corruption and manipulation, significantly impede the development of equitable health and economic infrastructure.18 19

In addition to the encouraging observations described in this report, there are a few aspects of the HRTCN SRs that make them potentially exciting for broad participation in global human rights activism. Many of the SRs submitted by the HRTCN were initiated by volunteer students who had little to no prior experience in human rights and tobacco control and were then reviewed by the senior author. Because they are ‘short reports’ as opposed to more comprehensive and longer shadow reports, they are more accessible for students or others who have little experience in legal or policy activism under the direction and supervision by individuals with relevant expertise. While this aspect may also suggest that SRs are at risk of being reductionist in their analysis of a given nation’s tobacco control policies, we argue that despite being condensed, these reports are not lacking in their analysis of complicated policy issues. SRs are primarily meant to educate the CESCR about critical tobacco-related issues. Since the CESCR’s Concluding Observations documents are in general similarly condensed, the nature of the HRTCN short reports may also add to their accessibility and to the ease with which the information can be directly included in the assessments. Overall, the SRs are shown to be moderately successful in demonstrating opportunities to involve laypeople and students in human rights and global activism, incorporating health, economics, policy and social justice issues and enabling them to make a documented impact.

Limitations

A limitation to our study is our surmising the influence of the HRTCN SR on the Concluding Observations without direct knowledge of the discussions or other unknown influences on the construction of the reports. Also, there was not an assessment of how the Concluding Observations influenced the state responses to the recommendations.

Conclusions

While the results described here may suggest that the HRTCN SRs have an impact on the CESCR’s inclusion of tobacco control issues in their Concluding Observations documents, what is unknown at this point is what effect the Concluding Observations may have on their respective nations’ actual policy decisions. It would appear that the CESCR and the United Nations treaties could have a significant influence on national policy decisions in many countries. Indeed, the WHO FCTC has had important positive impacts on the development of tobacco control policy worldwide. The CESCR could help to reinforce the FCTC and therefore could have an influence in countries that receive Concluding Observations recommending stronger tobacco control policies. Future efforts should include assessing the impact of CESCR recommendations on states actions to improve tobacco control as well as continuing to assess the influence of SR on CESCR tobacco control recommendations.

What this paper adds

  • The Framework Convention for Tobacco Control (FCTC) has weak enforcement mechanisms, and despite stellar adoption of the Convention, many countries lag significantly on its implementation.

  • There are several human rights treaties that most countries have also adopted, and these have regular reviews of submitted state reports. The reviewing committees for each of these treaties provide responses back to the state with recommendations for improvement in implementation of the respective treaty. The International Covenant for Economic, Social and Cultural Rights is one of the overarching human rights treaties with a Committee (The Committee on Economic, Social, and Cultural Rights (CESCR)) that meets several times a year to review and report back to states.

  • This paper provides an assessment of whether Human Rights and Tobacco Control Network submissions of Short Reports, as described in the paper, to the CESCR may affect resultant recommendations back to the respective state.

Acknowledgments

HRTCN is grateful to the numerous students who assisted in drafting the Short Reports form any of the countries and to Tori Nadel for assisting in the organisations of the timelines for these reports. We also thank Barb Lux who copied the reports and submitted these paper copies to CESCR. HRTCN credits the idea for our Short Reports to Professor Stephen Marks.

Acknowledgments

HRTCN is grateful to the numerous students who assisted in drafting the Short Reports for many of the countries and to Tori Nadel for assisting in the organisations of the timelines for these reports. We also thank Barb Lux who copied the reports and submitted these paper copies to CESCR. HRTCN credits the idea for our Short Reports to Professor Stephen Marks.

References

Footnotes

  • Contributors KH and JL did several of the original research on submitted HRTCN short reports and review of the CESCR submissions and reports. They drafted the initial version of the paper. HL, PhD, has overseen the work of KH and JL and multiple reviews of the paper. CD developed the idea, structure of the methodology and final oversight of the paper.

  • Funding The background work and research on this paper were done during volunteer and uncompensated time for all authors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.