Article Text
PDF
Abstract
Introduction Nigeria ratified the WHO Framework Convention on Tobacco Control (FCTC) in 2005. Tobacco control advocates in Nigeria achieved some success in countering tobacco industry interference to implement the FCTC.
Methods We triangulated interviews with key informants from local and international organisations who worked in Nigeria with documentation of the legislative process and Nigerian newspaper articles. Data were analysed and interpreted using the Policy Dystopia Model and WHO categories of tobacco industry interference that had been developed mostly based on experience in high-income countries.
Results As in high-income countries, the tobacco industry continued to oppose tobacco control policies after Nigeria ratified the FCTC, including weakening Nigeria’s 2015 National Tobacco Control Act. Both tobacco control advocates and industry used discursive (argument-based) and instrumental (activity-based) strategies. The industry argued self-regulation and the economic importance of tobacco. They exploited legislative procedures, used front groups and third parties to push for pro-industry changes. Advocates, with help from international organisations, mobilised prominent Nigerians and the public. Advocates pre-empted and countered the industry through traditional and social media, monitoring and exposing tobacco industry activities, and by actively engaging lawmakers and citizens during the legislative process.
Conclusion The Policy Dystopia Model and WHO categories of industry interference provide a helpful framework for understanding tobacco control debates in low/middle-income countries (LMICs) as in high-income countries. One difference in LMIC is the important role of international tobacco control advocates in supporting national tobacco control advocates. This partnership is important in pushing for FCTC-compliant legislation and countering industry activities in LMIC.
- advocacy
- global health
- low/middle income country
- public policy
- tobacco industry
Statistics from Altmetric.com
Introduction
WHO Framework Convention on Tobacco Control1 (FCTC) establishes evidence-based standards for tobacco control that provide a framework in which tobacco control advocates can play significant roles in securing comprehensive national tobacco control policies.2–6 Properly implemented FCTC policies significantly reduce tobacco consumption.7–10 Notwithstanding the progress in implementing tobacco control regulations globally, the tobacco industry remains a serious threat to public health.11–15 Low and middle income countries (LMIC) face extreme pressure from the industry to delay FCTC implementation.13 Efforts are necessary to counter tobacco industry interference with FCTC implementation to prevent the estimated 8 million deaths from tobacco-induced diseases annually by 2030, 80% of which will be in LMIC.16
Nigeria enacted its National Tobacco Control Act17 (NTCA) in 2015, 10 years after ratifying the FCTC and after several failed efforts to enact comprehensive tobacco control legislation.18 19 This study explores the role of tobacco control advocates and civil society organisations, including international organisations, in working for comprehensive tobacco control legislation in Nigeria, where the tobacco industry has had a strong presence.18 20 In contrast to the overall global reduction in smoking prevalence, smoking is increasing in WHO African and Eastern Mediterranean regions.21 Nigeria is particularly important to the tobacco industry due to its large population (170 million) and role as a regional trendsetter.18
The Policy Dystopia Model22 and the six categories of tobacco industry interference identified by WHO23 were developed using examples largely from high-income countries. We used these frameworks to assess the tobacco industry’s strategies to oppose tobacco control and strategies used by tobacco control advocates to push for FCTC-compliant legislation in Nigeria. The Policy Dystopia Model22 broadly categorises tobacco industry’s strategies into discursive (argument-based) and instrumental (activity-based) strategies. WHO classifies tobacco industry interference into six categories: (1) Manoeuvring to hijack the political and legislative process; (2) Exaggerating the economic importance of the industry; (3) Manipulating public opinion to gain the appearance of respectability; (4) Fabricating support through front groups; (5) Discrediting proven science and (6) Intimidating governments with litigation or the threat of litigation.23 This analysis reveals that both frameworks can be used to understand industry tactics, and to design and implement strategies to support FCTC-compliant legislation and counter industry interference especially in LMIC.
Methods
We interviewed 12 key informants between December 2015 and June 2017 from five local and international organisations involved in tobacco control advocacy in Nigeria (online supplementary table S1) using the interview guide in the online supplementary file. All the organisations participated in the rebirth of tobacco control activities during and after Nigeria ratified the FCTC in 2005, including some who participated in the legislative processes leading to the NTCA 2015. We attempted to contact government officials and legislators directly involved in the legislative process but none responded to our request for participation. Each interview lasted approximately 45 min and was voice recorded and transcribed. Participants gave consent to participate in the study before a date was fixed for the interview and formal consent was obtained from participants to record the interview at the beginning of the interview. Qualitative data from the interviews were analysed with Dedoose24 using thematic analysis25 with a priori themes derived from the analytical framework guiding this study. The first author conducted all interviews guided by an interview schedule (see online supplementary table S4) and the analysis of the data. The first author is an experienced researcher with a PhD in psychology and more than 5 years experience in tobacco control and in teaching qualitative research and analysis at postgraduate level. The second and third authors independently verified results of the analysis. When there were conflicts in the interpretation of the data, independent sources (newspaper articles and legislative documents) were sought to resolve them. Also, advocates were contacted where we could not find an independent source to resolve conflicting interpretations to get a second or third account to clarify a point.
Supplementary file 1
We retrieved Nigerian newspaper articles published between January 2008 (when the visible effort to pass a comprehensive law started19) and July 2017 using Google searches of key Nigerian newspaper websites (ie, Guardian, Vanguard, Daily Trust, Leadership, This Day, Premium Times). Search terms included ‘tobacco’, tobacco control’, tobacco law’, national tobacco control bill’ and ‘national tobacco control act’. Snowball search was used to find news articles which were mentioned in other articles. Copies of public hearing proceedings26 27 were obtained from the Campaign for Tobacco-Free Kids (CTFK) and Environmental Rights Action/Friends of the Earth Nigeria (ERA/FoEN). The interviews, news articles and written materials were triangulated to prepare this analysis of the development and passage of Nigeria’s law implementing the FCTC.
Results
Context of tobacco control in Nigeria and Africa pre-FCTC
Tobacco control advocates in Africa were rarely dedicated to solely tobacco control efforts28 and progress on tobacco control advocacy as a region has not been as fast as would be expected if a cadre of full-time advocates existed. Tobacco control advocacy in Africa was galvanised with the beginning of the FCTC negotiations in 2000.29 30 As momentum built during the FCTC negotiations in the early 2000s, international organisations including Corporate Accountability International30 31 (CAI, formally INFACT) and the Framework Convention Alliance (FCA) sought advocates in African countries, including Nigeria, to organise a regional advocacy community to participate in the FCTC negotiations.32 33 These international organisations funded by international partners (including grants from the Norwegian Cancer Society to FCA for their preliminary work in Africa33) provided small grants to local organisations including ERA/FoEN to conduct small scale research and grass-roots advocacy.31 33
The first of six FCTC Intergovernmental Negotiating Body (INB) sessions was in October 200034 where WHO member states, regional economic integration organisations and observers started the development of the FCTC. Civil society organisations with formal relations with WHO and other organisations participated in the sessions as observers.29 The tobacco industry was excluded from formal FCTC negotiations at the global level.35 Both the tobacco industry and civil society organisations were able to make submissions on the proposed text of the FCTC at a 2-day public hearing in Geneva in 2000 organised by WHO’s Tobacco Free Initiative.29 During the FCTC negotiations, African countries stood as a block coordinated by South Africa.30 The first pre-INB meeting in Africa was in Johannesburg, South Africa in March 2001, with four additional ones30 34 held in Algeria (October 2001), Cote d’Ivoire (February to March 2002), Malawi (September 2002) and Senegal (February 2003) before the sixth and last INB in February 2003.34 Africa’s pre-INB meetings helped its delegates (including Nigerian representatives) create a unified position and form the first regional voting block, providing strong regional support for the FCTC29 30 33 36 that set an example for other regions to follow.29
Tobacco industry and tobacco control advocates strategies following FCTC ratification
In 2005, Nigeria ratified the FCTC, the same year it entered into force, despite the tobacco industry’s financial and organisational strength used to stall the process.36 37 Consistent with its global strategies,23 the tobacco industry mobilised associates, front groups and politicians to counter efforts to formulate a comprehensive tobacco control policy after Nigeria ratified the FCTC (table 1 and online supplementary table S2). ERA/FoEN, backed by international organisations including FCA, CAI and CTFK,30 31 33 mobilised other Nigerian civil society groups (table 1) under the umbrella of the National Tobacco Control Alliance.36 The Alliance presented at public hearings, monitored tobacco industry activities and built capacity of journalists to report more accurately on tobacco control issues. Working together, tobacco control advocates solicited and received the support of ‘tobacco control champions’ who were prominent Nigerian citizens and politicians happy to work with advocates to achieve a tobacco-free Nigeria.38 39
Stakeholder organisations and agencies involved in tobacco control advocacy in Nigeria post-FCTC
While some of the tobacco control advocates’ efforts were aimed at countering the industry’s arguments and activities, many of the advocates’ actions were proactive and aimed at pushing for FCTC-compliant legislation in Nigeria.
Discursive strategies
Discursive strategies are argument-based strategies such as the alarmist narratives used by the industry to exaggerate the potential cost of a proposed policy while dismissing or denying its potential benefits.22 The tobacco industry and tobacco control advocates used discursive (argument-based) strategies to support their positions about the proposed law (table 2). These arguments were presented through the media and at legislative public hearings on the FCTC implementation bill.
Strategies used to undermine tobacco control in Nigeria and counter strategies used by tobacco control advocates
No need for a new tobacco law
The Nigerian tobacco industry (dominated by British American Tobacco Nigeria, BATN) argued that they were already ‘self-regulating’, making new laws unnecessary. Tobacco control advocates argued that the Federal Government of Nigeria needed to implement a comprehensive tobacco law consistent with the international standards in the FCTC and to save lives.36 38 39
Stretching the economic importance of tobacco
BATN claimed that it employed thousands of people.38 This claim was inconsistent with information on the BATN website obtained by tobacco control advocates, which showed BATN had only about 1000 employees.38 Tobacco control advocates used the information on BATN’s website to counter their claim; BATN subsequently removed information about their employment figures from its website.38
Foreign direct investment
With the return of democracy in the Third Republic in 1999, the Nigerian government sought foreign direct investment (FDI) to grow the economy which had suffered under previous military governments.18 This increase in foreign investors included multinational tobacco companies, notably BATN. During the legislative process for Nigeria’s tobacco control bills, BATN argued that a new tobacco control law would lead to the shutdown of foreign-owned companies and reduce FDI in Nigeria.38 Tobacco control advocates responded that there was no provision in the new law that would shut down foreign-owned companies.38
Instrumental strategies
Instrumental strategies are actions employed to influence policy-makers and other stakeholders for or against regulating tobacco.22 For example, the tobacco industry sought to make itself look like indispensable collaborators in national development through their corporate social responsibility (CSR) programmes; tobacco control advocates sought to expose the business motive behind these CSR strategies.
Use of front groups and third party affiliates
During the legislative process leading to the 2015 National Tobacco Control Bill, several organisations and groups previously unknown to be engaged in tobacco appeared to promote the tobacco industry’s positions36 (table 1 and supplementary table S2). For example, an organisation named African Liberty Organization for Development protested at the National Assembly during a public hearing on the tobacco bill and, among other things, asked legislators to pass a ‘balanced policy’ which would not only favour the majority (ie, non-smokers).40 Other organisations that made pro-industry presentations at the public hearing include Araga Farm Settlement, Nigeria Independent Tobacco Association and Habanera Limited (online supplementary table S2). In addition to third party allies, the industry was supported by prominent Nigerians, including past legislators and an ex-President, Chief Olusegun Obasanjo36 (table 1).
Tobacco control advocates mobilised at the grassroots to pressure the National Assembly during the public hearings (table 1). Other grassroots mobilisation activities included public awareness campaigns (including social media campaigns using the agency Paradigm Initiative of Nigeria39) and enlisting the support of prominent Nigerians (politicians and celebrities) who advocates called ‘tobacco control cause champions’.36 39 These champions included a professor (Yemi Osibanjo) who became Nigeria’s Vice Ppresident in May 2015, a former Minister of the Federal Capital Territory (Alhaji Aliu Moddibo), the wife of a former Chief Justice of Nigeria (Mariam Uwais), some members of the National Assembly, celebrities from Nigeria’s music and movie industry (Nollywood), including Stella Damascus, Fela Durotoye and Timi Dakolo).36 37 Some of these politicians and celebrities joined civil society groups at public hearings at the National Assembly on the tobacco control bills.
The efforts of the civil society groups were enhanced by the formation of the Nigeria Tobacco Control Alliance (Alliance) in 2005, an umbrella organisation specifically dedicated to tobacco control that became the face of tobacco control in Nigeria.37 The Alliance’s formation was important to consolidate efforts on tobacco control as many of the civil society groups had been working in isolation, and were also involved in non-tobacco control-related causes such as climate change, refugee care, environmental pollution and gender-related causes. With the passage of the NTCA in 2015, an Alliance representative was appointed to the Multisectoral National Tobacco Control Committee (NATOCC) charged with advising and working with the Federal Ministry of Health to implement the law.17
Corporate social responsibility
Corporate social responsibility (CSR) is supposed to be a philanthropic commitment made by businesses to bring them closer to their employees, families, and the communities where they conduct business.41 42 The tobacco industry uses CSR for image laundering, to gain political capital and to stymie regulatory processes.41–43 In a bid to manoeuver the political process and influence the Nigerian government, BATN extended its ‘goodwill’ activities to government agencies and politicians.36 Examples included BATN training the Nigeria Police Force in Lagos state on enforcement of the statewide tobacco control legislation and donating vehicles to the Nigeria Customs Service.36 44 BATN donated to non-governmental organisations owned by politicians, especially those directly involved in the tobacco policy-making process and created a ‘Political Liaison Office’ to cater for the welfare of politicians.36 BATN also sought the goodwill of farmers and members of the public by providing gifts to farmers (farming implements) and their children (scholarships) and organised award ceremonies for journalists38 in efforts to manipulate the public to view the industry positively.36 39 45
Tobacco control advocates established industry monitoring mechanisms to identify industry plans beforehand and counter them before they came to public knowledge.36 Advocates used press releases and newspaper reports to expose the industry’s planned activities and their motivations such as industry’s plan to train police officers in Lagos state and the establishment of a political liaison office.36 46–49 Advocates stopped many industry activities before they were executed but could not determine whether the industry abandoned these activities or later carried them out secretly to prevent public criticism.36 When held in secret, however, the industry lost their publicity value.36
Exploiting legislative provisions
While debates on the National Tobacco Control Bills 201150 and 201351 52 were ongoing in the National Assembly, legislators told tobacco control advocates that lobbyists and representatives of the tobacco industry were consistently visiting them.36 There was also an increase in positive media reports on tobacco industry activities to improve the industry’s image.36 Key informants reported that the industry may also have been working quietly to destabilise civil society groups through the introduction of bills to regulate the activities of non-governmental organisations and may have promoted two weaker tobacco control bills in both houses of the National Assembly between 2011 and 2013.36 These activities helped the tobacco industry in two ways. First, they enabled the industry to buy time by distracting both legislators and civil society groups from channelling their energy towards tobacco control during part of the legislative process. Second, the emergence of two weaker bills in the National Assembly watered down the strong tobacco control bill that the executive branch of government had drafted with technical assistance from CTFK19 45 (Efforts to interview the sponsors of the Senate bill, one of whom became a state governor in 2015, to gather more information about the origin of this bill were unsuccessful). Many of the weak provisions in those bills ended up in the final NTCA 2015, including: provision allowing designated smoking areas in higher educational institutions, hospitality and transportation venues, as well as, provision allowing tobacco manufacturers and retailers to communicate with ‘consenting adults’ which waters down the advertisement ban.19 26 27 36 38 53
The tobacco industry also directly pushed for provisions to make the law more industry friendly. Tobacco industry attendees at the public hearings on the NTCA (BATN, International Tobacco Company and Japan Tobacco International) partially succeeded in replacing strong tobacco control provisions with pro-business provisions (online supplementary table S2). In particular, the NTCA 201517 is the first Nigerian law to include a provision requiring the regulatory body charged with implementing the law to obtain approval of proposed regulatory guidelines by the National Assembly before implementing them.19 36 While this provision gives the tobacco industry another opportunity to delay or further weaken the NTCA, it also provides tobacco control advocates an opportunity to strengthen it.36 38 45 53 Despite being signed into law in May 2015, the implementing regulations of the law were yet to be approved by the National Assembly as of May 2018, effectively blocking full implementation.
Tobacco control advocates were well organised during the legislative process. They made presentations at public hearings on the tobacco bills highlighting the importance of strong laws to regulate tobacco, checkmate the tobacco industry and save lives. Advocates also mobilised individuals and groups to attend and present at the public hearings.26 27 36 38 53
State-level activities by tobacco control advocates
While working at the national level, tobacco control advocates successfully supported state-level tobacco control laws in Osun,36 38 Ekiti36 and Lagos states44 as well as the Federal Capital Territory,36 38 Abuja.36 As of May 2018, however, the authors are unaware of any plans to evaluate the effects of these state laws on overall FCTC national indicators. Tobacco control advocates used provisions in these state laws as a benchmark to push for stronger provisions in the national law. In Lagos state, for example, civil society groups secured a law prohibiting tobacco smoking in public transportation.36 Although, according to one key informant, the Lagos experiment was not very successful, civil society groups believed this approach opened a door that was previously thought to be closed in tobacco control in Nigeria.36
Discussion
Nigerian tobacco control advocates succeeded in securing the passage of the NCTA 2015 which is more comprehensive than the previous tobacco law, Decree 20 of 199019 through engagement with politicians and the media, as well as recruiting prominent Nigerians to campaign for a strong tobacco law. However, the tobacco industry succeeded in weakening the bill, with the resulting law falling short of effective FCTC implementation.19 The industry used front groups, third party allies and politicians to push for change in the draft law during the legislative process. Lobbying government officials54 55 and getting prominent politicians to speak in support of tobacco.56
The policy dystopia model
The Policy Dystopia Model22 is a helpful framework to systematically assess the tobacco industry’s strategies to oppose tobacco control in LMIC as well as the high-income countries where it was developed. In addition, it can be used to assess tobacco control advocates’ strategies to preempt and counter the tobacco industry in LMIC. Consistent with the Policy Dystopia Model, the Nigerian tobacco industry and tobacco control advocates used argument and activity-based approaches to influence the policy-making process. This finding suggests that the model can be used in LMIC to map and perhaps predict the tobacco industry’s tactics, allowing health advocates to develop strategies to preempt and counter tobacco industry interference. This knowledge can also guide governments and tobacco control advocates in designing effective measures like media campaigns targeting specific arguments and actions of the tobacco industry to protect tobacco policy from the industry.57
The strategies the tobacco industry used to interfere with tobacco control policy in Nigeria are similar to documented tobacco industry tactics in high-income countries22 23 58 and other LMIC,3 11 13 59–61 and as of May 2018 were still being used successfully in other countries, suggesting a need to restrategise tobacco control efforts around the world.62 It is important that documentation of these industry strategies be followed by action-based responses targeted at preempting and countering the arguments and activities of the tobacco industry.
Implications for Nigeria and other LMIC
One major reason tobacco control advocacy received a boost in Nigeria and achieved some success in preempting and countering industry influence was the increase in international technical support, training and funding. This experience is consistent with the results of similar support for civil society groups in other countries, including South Africa,5 Mexico,59 Costa Rica,63 Colombia,64 Uruguay65 and Thailand.3 In many African countries like South Africa, Burkina Faso, Tanzania, Nigeria and Kenya, civil society groups partner with government to achieve progress in tobacco policy formulation and implementation.61 This partnership mirrors international partnerships formed between health bodies like WHO and civil society groups including the FCA during FCTC negotiations. It is important that such partnerships continue to be replicated at national levels to preempt and counter industry interference and boost tobacco control in LMIC.
Despite enacting a more comprehensive law, the Nigerian government has not allocated local resources to engage in capacity building and to enrol more citizens and organisations in tobacco control advocacy efforts. Increased funding and better awareness of industry tactics at the grassroots will help consolidate the gains advocates have made at the national level and contribute towards effective implementation of the law. Nigeria and other governments should invest in media campaigns to educate their citizenry on different provisions of tobacco control laws to increase the chances of successful implementation. The Nigerian experience also confirms the importance of engaging celebrities, prominent citizens and the public to promote tobacco control, increase awareness about the law and support its implementation.19
Industry tactics in Nigeria reflect those used globally.3 5 54 55 59 It is likely that the lessons learnt from Nigeria about the tobacco industry’s strategies and how they can be preempted and countered can be applied or adapted for use in other African countries and other parts of the world. Continuous engagement with the international tobacco control community is essential to keep abreast with, and counter industry interference, including new developments such as the 2017 funding by Philip Morris International of the Foundation for a smoke-free world, another CSR effort.66–69 This engagement could include information sharing on counter strategies, training national tobacco control advocates on measures used to push back on tobacco industry influence, how to use the media to drive the tobacco control agenda of advocates and governments and sharing of human and material resources.
Nigeria is not fully implementing FCTC Article 5.3 which asked parties to protect tobacco policies from the vested interests of the tobacco industry.57 Engagement of the tobacco industry with government officials as described in this study, as well as the inclusion of the Manufacturer’s Association of Nigeria (MAN), which includes the tobacco industry as a member, on the NATOCC17 19 in charge of implementing the 2015 law, are clear indications that more work is needed by both advocates and government to protect tobacco control policy from the tobacco industry in Nigeria. NTCA 2015 stipulates that members of NATOCC not be affiliated with the tobacco industry and requires transparency of interactions between government and the industry.17 This provision would justify removing MAN from NATOCC. It is a lesson further for advocates and legislators to carefully scrutinise legislation language for loopholes that permit direct or indirect influence of the tobacco industry.17
Limitations
While the Policy Dystopia Model and WHO categories of industry interference provided good frameworks for analysis of tobacco control activities in Nigeria, these models presented challenges relating to the categorisation of argument and activity-based strategies and within WHO strategies of interference due to blurred differentiating lines between some strategies, for example, ‘manipulating public opinions’ was chiefly carried out by the industry under the guise of CSR. Also, we relied on information received from key informants in the advocacy community. Attempts to reach government officials from the National Assembly and the Federal Ministry of Health for interviews were unsuccessful, making it impossible to verify some claims by the key informants. Advocates working in Nigeria were also sometimes difficult to reach leading to delays in the data collection. As much as it was possible, newspaper reports were used to triangulate the data collected from interviews. Many of the advocates who previously worked for tobacco control in Nigeria have retired or are no longer engaged in tobacco control. These advocates could not be reached to provide information about early tobacco control advocacy activities in Nigeria. Interviews were conducted over a span of 3 years (2015–2017) in order to reach as many key informants as possible to participate in this study. Other limitations include the possibility of, recall bias, giving socially desirable answers and misrepresentations by interviewees. The triangulation of interview data with those of newspaper reports and legislative documents helped to address these possible limitations.
Conclusion
In Nigeria, like in many other countries, the FCTC has not stopped tobacco industry interference in tobacco policy formulation and implementation. The tobacco control advocates’ efforts in Nigeria yielded a more comprehensive tobacco control law for Nigeria in 2015, but as of May 2018, the law had not yet been fully implemented.19 The experience of tobacco control advocacy in Nigeria illustrates that the tobacco industry can be blocked if citizens partner with the government, media and the global tobacco control community. Tobacco control advocates acted to check both the government and the industry, especially when dealing with government agencies sympathetic to the industry or which perceived that sections of the tobacco control law were threatening their statutory duties. Consistent with the Policy Dystopia Model, establishing a framework for ongoing industry monitoring keeps the tobacco control community informed of tobacco industry activities and would likely be one of the best ways to counter industry interference in tobacco policy formulation and implementation. Importantly, while industry monitoring is important, what is done with the information from monitoring is more important. The information gathered from monitoring the industry must be documented, disseminated and used to design counterstrategies in order to successfully weaken industry influence in countries around the world.
What this paper adds
Framework Convention on Tobacco Control (FCTC) ratification has not stopped the tobacco industry from using well-established tactics to stall tobacco control policy in Nigeria.
The Policy Dystopia Model and WHO categories of tobacco industry interference provide a helpful framework for analysing and understanding the activities of the tobacco industry and of tobacco control advocates in Nigeria.
Tobacco control advocates in Nigeria were assisted through international technical support and funding.
Efforts of Nigeria’s tobacco control advocates helped in enacting a law which partially implemented the FCTC.
These lessons from Nigeria are transferable and adaptable for other low-income and middle-income countries and African countries.
Acknowledgments
We thank all key informants who participated in this study and the organisations they represent.
References
Footnotes
Contributors COE collected the data and drafted the paper. SAB and SG supervised the work and revised the paper.
Funding This work was funded by National Cancer Institute Grant CA-087472.
Disclaimer The funding agency played no role in the conduct of the research or preparation of the manuscript.
Competing interests SAB has consulted with WHO and the FCTC Secretariat since the early negotiations of the FCTC. Other authors have nothing to declare.
Patient consent Not required.
Ethics approval All interviews were conducted in accordance with a protocol approved by the University of California San Francisco Committee on Human Research.
Provenance and peer review Not commissioned; externally peer reviewed.