Attitudes towards FCTC Article 5.3 among tobacco control stakeholders in Thailand and their relationship with awareness of tobacco industry tactics

Introduction

Tobacco use causes more than 8 million deaths each year, including over 1 million from secondhand smoke.1 In 2003, the WHO Framework Convention on Tobacco Control (WHO FCTC), the first global health treaty, was established in response to the globalisation of the tobacco epidemic.2 The WHO identifies the tobacco industry as the most significant barrier to tobacco control since it is aggressively undermining tobacco control measures, opposes regulations and continues to impede the implementation of the WHO FCTC.3 To safeguard tobacco control policies from the tobacco industry’s commercial and other vested interests, the WHO FCTC Article 5.3 was adopted in 2008, with 4 guiding principles, 8 general and 34 specific recommendations.4 The fundamental conflict of interest between the tobacco industry and public health is highlighted in Article 5.3’s guiding principles (principle 1); thus, the guideline recommends that the government must be accountable and transparent (principle 2), demand accountability and transparency from the industry (principle 3) and refrain from providing incentives to the industry (principle 4).3 WHO recommended that the FCTC Article 5.3 be implemented in all branches of government that might be interested in or able to influence public health policy for tobacco control.3 Furthermore, WHO requires FCTC Parties to provide periodic reports to the Convention Secretariat on their efforts to implement its provisions, including Article 5.3, using a standardised questionnaire.5

In 2023, WHO reported that over 70% of the parties had adopted at least one measure recommended in the guidelines for Article 5.3 to protect public health policies from tobacco industry interference.5 Although the data indicates a notable rise since the guidelines were issued, it was unclear how effectively these were implemented, particularly in low-income and middle-income countries.6 For example, WHO has recognised Thailand as a good example of good practice in implementing the Article 5.3 guidelines. After Thailand ratified the WHO FCTC in 2004, it actively implemented several tobacco control policies, remarkably reducing overall smoking rates from 23% in 2004 to 17.4% in 2021.7 However, like other countries, the FCTC Article 5.3 is only recognised by the Ministry of Public Health.8 Between 2022 and 2023, non-health departments in Thailand were lobbied by a non-government organization linked to the Philip Morris-funded Foundation for a Smoke-Free World to revoke the ban on e-cigarettes.9 Therefore, the score for the section on the tobacco industry participation in policy development and implementation increased from 1 in 2021 to 10 in 2023 (the higher the score, the higher the overall level of interference) and Thailand’s ranking in the 2023 Global Tobacco Industry Interference Index dropped from 11 to 26.9

The obstacles to implementing Article 5.3 differ between nations. A common barrier to implementing Article 5.3 effectively was poor attitude and lack of awareness among government agencies, policy-makers, the general public and tobacco control stakeholders. Studies in Uganda, India, Bangladesh and Ethiopia found that levels of awareness and understanding of Article 5.3 were higher among officials in ministries of health and related health agencies but limited among non-health agencies.10 11 In 2018, a study conducted in the European Union (EU) discovered that key policy actors across EU institutions were generally unaware of the FCTC and Article 5.3.12 In 2023, a study in India found that individuals participating in tobacco control at the district level did not fully understand Article 5.3 and its guidelines.13 These studies explored awareness of Article 5.3 qualitatively but did not fully address all guiding principles and recommendations. Also, no studies have examined attitudes towards Article 5.3 among those involved in tobacco control and their relationship with awareness of tobacco industry tactics. This study explored attitudes towards Article 5.3’s guiding principles and recommendations among individuals engaged in tobacco control in Thailand and whether they were associated with awareness of tobacco industry tactics. In addition, we looked into whether different groups in Thai tobacco control held differing views on Article 5.3.

Methods

A self-administered online survey using Google Forms was conducted among three major groups of participants involved in tobacco control in Thailand: (1) tobacco control advocates supported by the Thai Health Promotion Foundation, (2) appointed experts of the Provincial Tobacco Products Control Committee (established by the Tobacco Products Control Act of 2017 to improve tobacco control at the local level) and (3) provincial tobacco control programme managers at Provincial Public Health Office.

To survey the first group, we obtained a list of current tobacco control projects from the Thai Health Promotion Foundation as of 1 April 2022. We then gathered names and contact information from project leaders, totalling 315 individuals. To identify participants in groups 2 and 3, we received names of active Provincial Tobacco Products Control Committee experts and programme managers from the Ministry of Public Health as of 1 April 2022. This yielded 313 provincial experts and 75 programme managers. Overall, 62.7% of participants responded to the survey. Members of Provincial Tobacco Products Control Committees (47.3%) responded less than tobacco control advocates funded by the Thai Health Promotion Foundation (67.9%) and Provincial Public Health Officials (92.0%).

The survey was deidentified to preserve privacy and encourage participants to report the truth.

Results

Discussion

This study found that FCTC Article 5.3’s guiding principles and recommendations were widely supported among Thai tobacco control stakeholders, although the level of acceptance slightly differed according to the participants’ characteristics. Among the four guiding principles of Article 5.3, the fundamental concept presented in principle 1, which asserts that the interests of the tobacco industry and the benefits of public health policy are irreconcilable, garnered the least support, especially among younger, less experienced and unaware of tobacco industry tactics. On the one hand, the brief and unclear statement of this principle in the questionnaire may confuse those with less experience in tobacco control. On the other hand, the statement of this principle might be too harsh for individuals who are less aware of the tobacco industry’s deceitful tactics. This basic principle must be promoted as a norm11 to raise awareness about tobacco industry interference. The norm should be clearly illustrated that tobacco companies are motivated to promote their products and attract new users to become addicted, which is contrary to public health policy.

Most participants agreed that all government agencies should limit interaction with the tobacco industry except to enforce tobacco control regulations regardless of whether the agencies worked with farmers and tobacco companies. This finding may differ from perspectives of non-health sectors in several countries, especially those from trade and finance agencies, which view tobacco companies as stakeholders, collaborators or major players in the country’s economy rather than interference.11 The high level of agreement across all government entities could be used to expand the implementation of the FCTC Article 5.3 guidelines beyond the Ministry of Health in Thailand.8

Since 2017, the tobacco industry and its front groups have lobbied the Thai government and politicians to revoke the ban on e-cigarettes.15 At least three Committees in the House of Representatives have been formed to discuss the legalisation of e-cigarettes.16 17 Controversially, these committees appointed people with ties to the tobacco industry to advisory boards or committee members, which violated FCTC Article 5.3.¹⁸ Thai tobacco control advocates submitted letters to the President of the Parliament to revoke these people from the committee due to the violation of Article 5.3, but there has been no response.18 19 Although this practice contradicts the survey result that 95% of respondents thought the tobacco industry’s representatives should not be permitted to hold a position on any committee or advisory group that develops or carries out public health or tobacco control policy, limited awareness and engagement beyond health sectors is a common barrier to implement Article 5.3 in Thailand and other countries.10

This study supports that tobacco industry denormalisation should be a critical success in effectively implementing Article 5.3. The tobacco industry denormalisation is the strategy of educating people about the deceitful tactics of the tobacco industry.20 It presents the tobacco industry’s actions as aberrant and deviant rather than normal in terms of society and the economy.20 According to a study, those who are aware of the tactics used by the tobacco industry are more likely to have negative attitudes towards the tobacco industry.21 This study also found that awareness of tobacco industry tactics is positively associated with agreement on Article 5.3’s guiding principles and recommendations. It is critical to broaden the scope of Article 5.3 awareness campaigns to include the entire government and the public. Furthermore, due to the level of agreement in Article 5.3’s guidelines differing by participants’ characteristics, appropriate campaigns or capacity-building programmes should be designed accordingly. For example, this study found that younger respondents were less likely to agree with Article 5.3’s guiding principles. Because youths are a primary target of the tobacco industry, it is crucial to increase youth awareness of tobacco industry tactics and encourage them to create innovations and take action against the tobacco industry.22 Moreover, the Ministry of Public Health, which oversees provincial public health officials, should ensure that these officials are regularly trained on tobacco measures and tactics of the tobacco industry, including establishing a network to monitor tobacco industry interference at the provincial and national levels.

Conclusions

This study provides quantitative evidence of the association between views towards WHO FCTC Article 5.3 and awareness of tobacco industry tactics in Thailand. Denormalisation of the tobacco industry should, therefore, be a critical component of successfully implementing Article 5.3. This study also revealed that Thai tobacco control stakeholders broadly supported Article 5.3’s guiding principles and recommendations; however, a lack of understanding of the core norm of Article 5.3 should be addressed. In addition to awareness of tobacco industry tactics, age, years of experience in tobacco control, role in tobacco control, and smoking by family members and friends were also associated with perspectives towards Article 5.3.