Results

COMMON PREOCCUPATIONS

Research themes were consistent across all three regions, with small variations that may reflect the make up of individual discussion groups and/or emerging issues in specific regions. Throughout all discussions, participants focused on tobacco as a multidisciplinary issue, considering both the production and consumption aspects of the equation. The cultivation of tobacco, its importance as a form of employment, historical and cultural uses of tobacco, trade implications, marketing strategies, changing societal norms, and environmental issues were seen as an integral part of the tobacco issue. Participants at all three workshops repeatedly came back to the following research priorities:

(1)

The lack of standardised and comparable data—The most recurrent theme at all three meetings was the need for regional surveillance systems and research to provide baseline data on: the prevalence of tobacco use; consumption patterns and trends; patterns of and trends in tobacco-attributable morbidity and mortality; existing policies and programmes; and ongoing and completed research initiatives. While a certain amount of material exists, databases of this nature are costly to maintain. What is especially needed is detailed information broken down by sex, age group, populations at risk, and regions and provinces.

(2)

The absence of a network for communication of information, data, and best practices—While many of the electronic networks have contributed positively to the discussion of tobacco control, they are not universally accessible in the developing world. The absence of a network was perceived as a major impediment to collaboration and partnership in all regions. Consistent with this was a desire by all regions to conduct a mapping exercise to identify: the current stakeholders in tobacco control initiatives; research institutes and researchers currently involved in tobacco control; and the needs and activities of the whole tobacco control community—including researchers, advocates and policymakers—so as to harmonise efforts and mechanisms of control.

(3)

Lack of adequate capacity for tobacco control research, especially in non-health related areas such as economics and policy analysis—The current and potential socioeconomic burden of tobacco production and consumption underscores the need to bolster research capacity in developing countries. A scarcity of skills and competence for multidisciplinary and policy research is compounded by the failure of donor agencies to be proactive in funding research on evolving issues.

(4)

A need for concerted mobilisation of human and financial resources in order to implement a comprehensive research agenda, build partnerships and stimulate comparative research and analysis.

SPECIFIC RESEARCH ISSUES

Most of the specific research issues were descriptive in nature and related mainly to the supply side (table 1).

In addition, there was an interest in doing more detailed and analytical studies both on the supply and demand sides. These are summarised in table 2.

DIVERGENCES IN EMPHASIS AND APPROACHES

Commonalities notwithstanding, there were evident differences between the three regions in terms of emphasis and approaches to research and capacity building. Specifically, there was a greater preoccupation in the African meeting with documenting who profits most from tobacco production, trade and manufacturing, and how much of those profits remain in the country and with the farmers themselves. In Latin America, the participants focused on epidemiological issues, including the paucity of baseline consumption and burden-of-disease data, and the behavioural aspects of tobacco use. The Asian and African delegates, on the other hand, were more concerned about the influence of advertising and endorsement, and how to curtail them while they are still embryonic. Trafficking came up repeatedly in Latin America and in Africa. Asian representatives also discussed an extensive taxonomy of those involved in the chain of supply; the inter-relationships between and impact of each sector; and the behavioural determinants of tobacco use.

For Latin Americans, health education was predominantly a question of programme content. The Asian and African meetings discussed in detail: target groups; agents of change; the optimal mix of strategies in a comprehensive programme; the effectiveness of each component; methods and means of communication; and underlying behavioural models.

In discussing research on tobacco control policy, the Latin American meeting clearly elaborated the need to look at all types of legislation with respect to tobacco: economic, agricultural and environmental policies, as well as health policies. The Asian and African meetings focused on: who the players should be; the attitudes of policymakers and how to influence them; and how to empower not only decision-makers, but also policymakers, opinion leaders, religious leaders and women.

In discussing emerging issues, participants at all three meetings expressed a need to harmonise taxes and prices across each region. Latin American delegates reiterated the need for a regional surveillance system to collect data on cross border TTC strategies. Asian delegates discussed the impact of international trade agreements and the contribution of tobacco to the economy of the region. They also examined the changing nature of advertising and product mix in the context of increasing purchasing power and levels of education and urbanisation. The African meeting identified policy instruments (duties, subsidies, advertising and marketing controls), as well as policing and enforcement of policies. Also highlighted were trade issues, including regulation versus liberalisation of trade, and the impact of loss of government controls; building and strengthening regional research capacity; and capacity for litigation, all in the context of the South African Development Community.

With respect to overall approaches, Latin America differed in perceiving research as a somewhat separate endeavour in its own right. In Asia and Africa, on the other hand, there was some reluctance to think of research as separate from advocacy and tobacco control measures. In Asia, there was genuine interest in collaborative work, albeit along the traditional dividing lines of South and Southeast Asia. The Latin American participants showed somewhat less interest in intercountry collaboration, despite the cultural similarities within the region. In Africa, the participants advocated a more equitable partnership in terms of access to funding and capacity building across the region.

Discussion

Given the scarcity of funds available for tobacco control research globally, it is imperative that donors and the research community help to develop and agree on research priorities that will have the largest impact on populations and vulnerable groups in the developing world. Several attempts have been made to define priorities for research to curtail tobacco use and prevent or limit the burden of illness that it causes. The working group that was convened at the 10th World Conference on Tobacco or Health in Beijing came up with the following five recommendations: that the practices of the tobacco industry be investigated; that the proper mix of policies be identified through research; that transnational factors in tobacco use be studied; that a balance between research needs in terms of prevention and cessation be found; and that national level research be complemented by both subnational and international research.12 They further agreed that multidisciplinary research is key to effective interventions and policies. Their report called on the donor community and United Nations agencies to increase their funding and support to tobacco control research, and find ways and means for an effective partnership.

In a second attempt, an international committee of 13 members representing a broad expertise in the prevention and control of cardiovascular diseases was convened by the Institute of Medicine (IOM) of the US Academy of Sciences to prepare a report on cardiovascular diseases in developing countries. Their report, published by the IOM, also recommends five research subjects to reduce tobacco use.13 These are: prevalence studies of tobacco use in developing countries; time series to monitor tobacco consumption trends, especially in segments of populations most at risk such as children, adolescents and women; evaluative studies to determine the cost effectiveness of community based interventions to prevent smoking and of tobacco cessation programmes; and economic studies to estimate the total impact of tobacco production and consumption in a developing country context.

The regional workshops convened by RITC in Latin America, Asia, and Africa largely concurred with the two previous attempts at setting a research agenda for tobacco control, especially with regard to issues identified under the rubric of consumption.

The first of these was to improve knowledge of the size and nature of the tobacco related burden of disease in developing countries. All three regions expressed a need to develop regional surveillance systems that would provide baseline data and ongoing monitoring of patterns of morbidity and mortality associated with tobacco use.

The second was to establish the levels, determinants, and consequences of tobacco use. The most frequently stated research need at all three regional meetings was the need for data collection related to the prevalence of tobacco use and consumption patterns at the local, national, and regional level. The need to identify the determinants of tobacco use and non-use, as well as those groups most at risk, and to describe the nature of underlying peer pressure was also stated.

The third was related to public health interventions. The regional meetings hosted by RITC were specifically designed to emphasise the role of policy based research. All three regions expressed a desire to document and assess the impact of policies that relate to tobacco use, including health, economic, agricultural, environmental, and international trade policies. All three groups took the opportunity to brainstorm about the optimal composition of a comprehensive national tobacco control strategy, developing extensive “wish lists” for programmes, policies, and evaluation. They discussed the role of different factors in a comprehensive strategy and which sectors should be involved in developing and implementing such a strategy.

The RITC meetings and the two previous agenda setting meetings also agreed on the importance of capacity building and information sharing. The working group convened during the 10th World Conference on Tobacco or Health noted that lack of expertise in tobacco control and even basic data collection left many developing countries vulnerable to aggressive market penetration by multinational tobacco corporations.12 The IOM committee identified the need to train investigators, and strengthen links between basic, epidemiological, clinical, and policy research in order to foster a problem-solving, multidisciplinary approach.13 The participants in the three regional RITC meetings not only recognised the need to build capacity for tobacco control research, they also began taking steps to do so. All three regions are preparing proposals to submit to RITC for the establishment of networks to facilitate information sharing, capacity building, and the development of multidisciplinary local, national or regional research teams (table3).

Moreover, in spite of major similarities between the recommendations made in the three attempts to set a research agenda, the process adopted by RITC emerged as unique.

• First, by design and by virtue of the mix of participants, the RITC meetings and resulting agenda were more multidisciplinary and went beyond the field of health and health care research.

• Second, the regional workshops went further in their attempt to set research agendas by identifying a number of issues on the supply side that are directly related to the larger development context.

• Third, because of the more participatory and inclusive process followed in the regional workshops, researchers in the south are more likely to buy into these regional agendas.

The magnitude of the tobacco epidemic dictates that tobacco control research must be a significant component of the global health research agenda. The participation of stakeholders from developing countries at the regional meetings sponsored by RITC ensured that a broad range of issues relevant to each area was considered. As a result of their involvement in setting research priorities, researchers in the three regions are anxious to initiate projects that will address them. As tobacco control takes its rightful place on the global health agenda, it is important that funding for tobacco control research be increased. Significant gaps in information have been identified at the regional meetings. These data are urgently needed to provide a sound basis for the development of policies and programmes to curtail the devastation brought about by tobacco. In this respect, as well as supporting the development of regional networks and policy relevant research in the south, RITC is prepared to work with others to advocate for global tobacco control research.