Awareness and relevance of the FCTC

Within UKOT governments, awareness of the FCTC was limited to those civil servants directly engaged in tobacco control. Such officials showed generally strong awareness of the treaty and regarded it as a valuable benchmark for tobacco control actions. Commitment to the treaty was understood as a prerequisite for its extension to the territories, and there was a desire among health policy advisors to ‘tick as many and all of the boxes around FCTC’ and ‘try to fill the FCTC gaps’ based on ‘exactly what it is that is required’. The FCTC was presented as an external frame of reference for tobacco control legislation. As explained by one health official:

…when we were drafting the law, that was our guiding document, and so that’s why we’ve been able to draft the law in such a way that it’s compliant with almost all the articles, so that was our guiding tool, our guiding document.

Alongside embodying international best practice, the FCTC was invoked by policymakers as offering political leverage in justifying decisions affecting the business community. Interviewees who had worked on tobacco legislation suggested they could ‘almost blame the FCTC’ in responding to local business concerns by presenting compliance in terms of ‘this is what we have to do’. In the words of one health official:

It sort of helps us to be able to say, ‘this is the best practice’…[] Particularly for decision-makers when they’re being faced with potentially having to make a decision that might not be popular with some of their constituents in the business community, to have something like the FCTC to say ‘this is what the UK is committed to, this is what people around the world, governments around the world are looking at’.

Article 5.3, ambiguous understandings of the tobacco industry and conflict of interest

The FCTC’s political functions extended to aiding management of industry interference, notwithstanding generally limited awareness of Article 5.3. One official described addressing members of the Chamber of Commerce and “tell(ing) them to their faces, ‘no, we didn’t consult you because the FCTC said I don’t have to consult you’”. Another civil servant described using Article 5.3 to limit their health ministry’s interactions with industry actors:

This is where the WHO framework came into play. The WHO framework specifies that you do not consult with industry stakeholders because they have a way of trying to navigate around and see how they can circumvent [proposed restrictions]. I think that mistake was made by the ministry once, and then when I started drafting the legislation it stopped.

Awareness of tobacco industry interference in the UKOTs was similarly restricted to those with direct experience in developing new legislation. In Bermuda and Cayman Islands (territories that had recently passed tobacco control legislation), health officials described how representatives of transnational tobacco companies had attempted to block proposed measures. One tobacco lead noted the potentially damaging impact of such interference:

We weren’t even confident [the draft legislation] was going to get put back on the agenda because we were having all this pressure from the outside, like I told you, British American Tobacco, Japan Tobacco, Philip Morris. They were in Bermuda, they were sending us lawyers’ letters… they were asking for private meetings with the minister and were advising the minister not to [support it].

In considering prospects for introducing standardised packaging of tobacco products, the same interviewee expressed concern that the tobacco industry “may tie us up in knots, if we decide to [go ahead with it], spend some real money to make an example of us. And we don’t have the money”.

In contrast, most interviewees saw tobacco transnationals as lacking interest in the UKOTs (given their small populations), and regarded their territory as free from industry influence. A handful of respondents (with experience of developing tobacco legislation) recognised diverse faces of the tobacco industry and the potential for local commercial actors to advance wider industry interests. One civil servant engaged in developing legislation saw the main sources of ‘pushback’ as being ‘retail, Chamber of Commerce especially. The owners of the smoke shops, retailers selling it, wholesalers especially’; while a health policy advisor was similarly less anxious about opposition from tobacco transnationals and ‘more concerned about the shopkeepers, even the hotels’.

In some territories, political sensitivities were heightened by specific instances of local, small-scale tobacco production. In the Cayman Islands, interviewees expressed concern about tobacco being locally grown at a residential rehabilitation centre as a way of generating revenue. Several participants in Bermuda mentioned a local retailer (the ‘Smoke Shop’) that imported loose-leaf tobacco and manufactured cheap cigarettes for local sale. A local politician expressed concern about the impact of tobacco regulations on local retailers (“the ‘ma and pa’ stores”) that sold single cigarettes in low-income neighbourhoods but were seen as supporting the local community rather than acting to protect industry interests. Similar perceptions shaped several interviewees’ understandings of appropriate interactions in policy contexts. Some health officials spoke of the desirability of involving local retailers, importers and businesses on legislative advisory committees, which were presented as spaces where policymakers could negotiate a balance between health and economic priorities. As one tobacco lead explained:

We wanted to get their input as a tobacco dealer, and how it would affect them, what we could do to create compromises. The main thing was whether or not it was going to affect the businesses.

In contrast, interviewees experienced in developing tobacco legislation saw local importers, retailers and chambers of commerce as acting on behalf of the tobacco industry—as reflected by a local politician:

I mean, there was resistance. I remember being lobbied, in fact […] being lobbied by the tobacco industry. What it really was, was one of the biggest distributors of Bermuda, importers of tobacco products, and he had us come to his office and spoke about [proposed tobacco control legislation]. I walked out thinking, I’m being lobbied by tobacco.

Such interviewees referred explicitly to conflicts of interest and the desirability of excluding industry-affiliated actors from policy discussions. However, they also recognised practical constraints arising from the territories’ economic reliance on tourism and hospitality. In discussing how to address such tensions, one health official noted, “it’s not going to be easy. I don’t know how it’s going to work because of the relationship that all the leaders have with these entities, these hotels”. Another civil servant asked “which politician is going to tell the big fancy [tobacco importer] giving him millions of dollars to run their old campaigns—that they can’t do this and they can’t do that?” Managing government-industry interactions was particularly difficult where key politicians were financially invested in the tobacco industry. In describing politicians’ reluctance to advance tobacco control, an interviewee from a local charity explained “I think there’s a couple of [politicians] that are either wholesale importers or they are retailers”.

Challenges of promoting coordination and coherence

The challenge of limiting government-industry interactions is compounded by a perceived tension between tobacco control and territories’ economic reliance on tourism and hospitality.16 According to one health official, “everything that is big business is related to tourism in some shape or form […] we don’t have any other investments; it’s the only industry, the only way to make money”. Such tensions add to challenges in developing a coordinated whole-of-government approach to tobacco control. Several health officials identified the need to work across policy silos, highlighting how effective tobacco control and non-communicable disease (NCD) prevention required a coordinated approach. In the words of one tobacco lead: “Because we realise that chronic disease interventions are beyond health…we [need to] get all sectors involved, all persons involved”. Interviewees working in health policy expressed a desire for more intersectoral engagement, arguing that ‘having agencies like the Drug Council who are pushing from other directions and helping also to educate the public is really important as well’.

In practice, however, tobacco control efforts were largely confined to health with limited engagement across sectors such as commerce, education, customs and drug policy. One civil servant working in drug prevention was unaware of their territory’s tobacco policies, while another noted that tobacco control had ‘primarily been a feature of the public health department’ with a lack of joined-up policy: “the tobacco framework, while we put it into legislation, when we develop other public health policies, other drug policies, it’s not being tied in”. Several interviewees would welcome more intersectoral engagement, which was often seen as a consequence of limited public sector capacity. An interviewee from a local charity recalled a multistakeholder committee being created to advance a piece of legislation, but such coordination was rare and ad hoc, being established for a specific time-limited purpose and then dissolved. One health official described a general sense that different departments ‘do not work well together’ with a lack of ‘inner-working’ across diverse parts of government.

As indicated above, human resource constraints—characteristic of small island contexts13 15 18—were seen as limiting scope for intersectoral coordination. Lack of capacity was frequently cited, with one civil servant outside of health describing their department as “a staff of six or seven, expected to do all of this, but we certainly don’t have the funding to … have the capacity to inform”. Staffing issues were also seen as an obstacle to intersectoral collaboration in enforcement, as described by a health protection officer:

We are probably understaffed here, and we have other concerns. I think you also have to collaborate a lot with customs, that will be your first line of defence so to speak. And I know right now there’s not a lot of—I should say there’s not any like customs officers responsible for port health, there’s not that sort of training within that staff.

Interviewees spoke of reliance on personal connections in compensating for the lack of formal coordinating structures, with high levels of social connection seen as providing an alternative means of informal communication. As one civil servant noted:

Because we are so close knit, you know, we have weekly meetings where we will discuss it and say, oh, by the way did you know? And they will pick it back up again. They will say, oh, we will send an email to the ministry, which is totally outside of [own department]. But because we’re such a small jurisdiction, we understand, okay, well, maybe these guys forgot about it or maybe they didn’t think about [doing that].

Significance of international cooperation to tobacco control

Alongside limited intersectoral collaboration, tobacco control officials often reported experiencing professional isolation—which could lead to feelings of being ‘dragged down’ and ‘discouraged’. Officials particularly valued opportunities for international engagement and support—opportunities that are constrained by the UKOTs’ lacking statehood and full WHO membership status. Interviewees spoke of the benefits of regional links, notably those created via PAHO and Public Health England (PHE). One tobacco lead talked of the UKOTs’ inclusion in a PAHO workshop as “the first time we were all meeting together and we learned so much from each other”. Another interviewee spoke of the encouragement colleagues derived from learning that ‘actually small islands have done it (tobacco control) and have done it successfully’, adding that—on return to their home territory—the relevant politicians ‘had this renewed zeal about’ advancing tobacco control measures.

Meetings with other UKOTs and Caribbean states provided spaces where health officials could exchange knowledge and share practices for responding to their contextual challenges. One health official discussed the importance of lesson learning in navigating complex conflicts of interest generated by close relationships between politicians and industry actors:

We have to realise we live in the Caribbean, we’re political […] those persons that finance tobacco were approaching the politicians to [say], ‘I will finance your campaign, I will give your island X amount towards education, however, you need to ease some pressure’. So because you know that was coming, even before that conversation started […] when you went to executive council […] you could have showed them the pros and the cons [of engaging with industry-funded donors], because you already had that [awareness].

Support from WHO and its regional offices was similarly seen as important for territories’ efforts to advance tobacco control. In the case of St Helena—which is more isolated than the Caribbean territories and lacks a regional ‘peer group’—policymakers benefited substantially from a WHO-funded visit to Mauritius. A local politician described the visit as enabling them “to look at the patterns of chronic diseases, what support measures they had in place, and see what we could take from them in terms of lessons learned”.

Interactions with WHO are constrained by the distinctive legal status of the UKOTs. Nevertheless, health officials in the Caribbean territories clearly regarded their ‘longstanding’ relationship with PAHO as invaluable. There was a sense that ‘PAHO is our grandfather’, providing technical and political support and linking health officials in the territories with counterparts in other Caribbean jurisdictions. Alongside PHE, cooperation with PAHO was seen as relevant in seeking extension of FCTC coverage. PAHO’s engagement with the territories was perceived as offering leverage for tobacco control across different sectors—as explained by another health official:

PAHO sends us a questionnaire annually and says, well, here’s the MPOWER, you know, how do you rate yourself? […] this questionnaire arrives and then you have to circulate [it] to colleagues and customs and they’re like, ‘Oh, this is serious, this is from PAHO’. Then, you actually have to get data. Yes, it’s great. It’s fantastic.

Alongside such regional interactions, officials emphasised the benefits of engagement with the international tobacco control community. One tobacco lead described the revelatory power of participation in the World Conference on Tobacco or Health:

[I]t was amazing to see everybody reporting on the FCTC and recognising what a powerful convention that is. Then, some of these countries that were standing up and saying, you know, ‘tobacco-free Ireland’. Some of the Scandinavian countries, Finland maybe, was just like, oh, my god. It was amazing. Yes, it was almost like a religious experience. You’re like, holy cow, this is public health.