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South-to-South Collaboration and Capacity Building for International Tobacco Control

Final Technical and Financial Reports (June 2003 – December 2006)

Prepared for: Canadian Partnership Branch, Canadian International Development Agency

Prepared by: HealthBridge (formerly PATH Canada) Project Number S62163 Purchase Order 7027508 GLAcct/CC/Fund: 52303/06113/0310 Vendor: 0001000926

February 2007

A multi-country collaboration among Southern partners to enhance capacity building for international tobacco control

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TABLE OF CONTENTS Executive Summary List of Acronyms Acknowledgements 1 INTRODUCTION ............................................................................................................................................2

1.1 CANADIAN AND PARTNER ORGANIZATIONS.............................................................................................2 1.2 GOALS AND OBJECTIVES..............................................................................................................................5 1.3 OVERVIEW OF KEY PROJECT SUCCESSES .....................................................................................................5

2 CONTEXT AND RATIONALE......................................................................................................................6 2.1 GLOBAL TOBACCO CONTROL CONTEXT.....................................................................................................6 2.2 SELECTION OF S2S PARTNER COUNTRIES...................................................................................................7 2.3 POLITICAL CONTEXT OF TOBACCO CONTROL............................................................................................8 2.4 DONOR LANDSCAPE SUPPORTING TOBACCO CONTROL IN S2S COUNTRIES ............................................9 2.5 RATIONALE FOR THE S2S PROJECT ...........................................................................................................10

3 OVERVIEW OF THE SOUTH TO SOUTH (S2S) PROGRAMME .......................................................11 3.1 INTRODUCTION..........................................................................................................................................11 3.2 COMPONENT A: RESEARCH .....................................................................................................................13 3.3 COMPONENT B: MEDIA ENGAGEMENT ...................................................................................................15 3.4 COMPONENT C: GOVERNMENT SUPPORT................................................................................................20 3.5 COMPONENT D: CAPACITY BUILDING AND TECHNICAL ASSISTANCE...................................................24 3.6 COMPONENT E: NETWORKING ................................................................................................................27 3.7 COMPONENT F: PUBLIC EDUCATION.......................................................................................................31 3.8 COMPONENT G: PROJECT MANAGEMENT ...............................................................................................33

4 RESULTS: GOAL ACHIEVEMENT...........................................................................................................35 4.1 ASSESSMENT OF OUTCOME 1 ....................................................................................................................36 4.2 ASSESSMENT OF OUTCOME 2 ....................................................................................................................43 4.3 ASSESSMENT OF OUTCOME 3 ....................................................................................................................49 4.4 ASSESSMENT OF IMPACT............................................................................................................................54 4.5 ASSESSMENT OF VARIANCES.....................................................................................................................55

5 RISKS AND ASSUMPTIONS .....................................................................................................................56 5.1 ASSUMPTIONS............................................................................................................................................56 5.2 OUTPUT LEVEL RISKS ................................................................................................................................56 5.3 OUTCOME LEVEL RISKS.............................................................................................................................57 5.4 IMPACT LEVEL RISKS .................................................................................................................................57

6 GENDER EQUALITY ....................................................................................................................................59 7 PUBLIC ENGAGEMENT..............................................................................................................................61 8 SHARED RESPONSIBILITY AND ACCOUNTABILITY ......................................................................62 9 SUSTAINABILITY.........................................................................................................................................63 10 LESSONS LEARNED.....................................................................................................................................65 11 ASSESSMENT OF ENVIRONMENTAL RESULTS ................................................................................68 12 PROJECT EVALUATION.............................................................................................................................68 13 GOODS PURCHASED FOR THE PROJECT............................................................................................68 14 PERFORMANCE TO BUDGET...................................................................................................................69

14.1 EXPLANATION OF VARIANCES ..................................................................................................................69

South‐to‐South Collaboration and Capacity Building for International Tobacco Control Final Report

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APPENDICES APPENDIX A: CPB PLANNING SHEET APPENDIX B: CIDA DECLARATION DOCUMENTS APPENDIX C: FINAL EVALUATION REPORT, BANGLADESH APPENDIX D: TABAC ET PAUVRETE AU NIGER – RESULTATS D’UN RECHERCHE APPENDIX E: IMPLEMENTING ANTI‐TOBACCO STATUTES IN PAKISTAN: A DEVELOPING COUNTRY PERSPECTIVE APPENDIX F: HEALTHBRIDGE’S SOUTH‐TO‐SOUTH TOBACCO CONTROL PROGRAM: LESSONS LEARNED

LIST OF FIGURES FIGURE 1 HEALTHBRIDGE S2S PARTNERS ...................................................................................................................1 FIGURE 2: OVERVIEW OF S2S PROGRAMME COMPONENTS ......................................................................................12 FIGURE 3: PROJECT MANAGEMENT STRUCTURE .......................................................................................................34 FIGURE 4: OVERVIEW OF S2S PROJECT OBJECTIVES AND PLANNED OUTCOMES .....................................................35 LIST OF TABLES TABLE 1 SELECTION OF PARTNER COUNTRIES .............................................................................................................7 TABLE 2: ACHIEVING OUTCOME 1.............................................................................................................................36 TABLE 3: ACHIEVING OUTCOME 2.............................................................................................................................44 TABLE 4: ACHIEVING OUTCOME 3.............................................................................................................................49 TABLE 5: CPB PROJECT PLANNING SHEET................................................................................................................71 EXECUTIVE SUMMARY The South‐to‐South Collaboration and Capacity Building for International Tobacco Control programme (S2S), implemented by HealthBridge over the period June 2003 to December 2006, achieved significant results geared towards reducing tobacco use and its detrimental consequences on health, poverty, and the environment. Specifically, the programme has demonstrated strengthened capacity in six partner countries to develop and implement key tobacco control policies, to undertake research, and to develop and implement tobacco control programs. The end of project internal evaluation indicated that the S2S programme addressed significant gaps in tobacco control policy development and support and in increasing public and government awareness of tobacco control issues.

S2S programme was designed to (i) strengthen key tobacco control policies in six countries by building capacity of Southern partners to advocate for these policies and to engage in effective tobacco control measures, (ii) strengthen South‐to‐South collaboration and networking, and (iii) build public knowledge and support for tobacco control policies. In each of the six countries, both Government and NGO capacity to develop and advocate for strong tobacco control policies and laws has been improved, and HealthBridge’s project partners have enhanced their capacity to act as leaders both within their own countries and regionally. Tobacco control networks were developed or strengthened in all six countries, and hundreds of new organizations became involved in tobacco control. Public awareness of and support for tobacco control has increased in all six countries, as has media coverage of the subject. The media is now more engaged in tobacco control efforts, and is less influenced by the tobacco industry. The research capacity of HealthBridge’s six local partners has increased; the results of their research has been nationally, and in some cases internationally, recognized.

The overall goal of the S2S programme was “To reduce tobacco use and its detrimental consequences on health, poverty, and the environment in six low‐income countries (Bangladesh, India, Nepal, Niger,

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Nigeria, and Vietnam) by strengthening the countries’ capacity to develop and implement key tobacco control policies (smoking restrictions, warnings for tobacco products, bans on tobacco advertising and promotion, and higher taxes on tobacco products), research, and programs.” Significant measurable progress has been made in making tobacco control a priority in each of the six countries which will, in the future, most likely lead to reduced rates of tobacco use and ultimately of tobacco‐related morbidity, mortality, poverty, and environmental consequences. Further, a key lesson of the program for governments is that they can and should take responsibility to curb the activities of companies when such activities are detrimental to public health or the environment.

HealthBridge sought to increase the capacity of local NGOs and build a strong international network among them to reduce their reliance on technical and ultimately financial assistance from developed countries. The enactment and enforcement of tobacco control laws in each country means that the programme will continue to achieve benefits far into the future. Ownership of the programme and of the S2S network through participatory approaches in the design, implementation, and evaluation of the programme will also contribute to longer term sustainability. Collaboration and sharing of information, lessons learned, and methodologies with other local organizations, international agencies and other funders further enhances the potential long‐term reach and effect of the programme.

LIST OF ACRONYMS:

ACS American Cancer Society AFTC Advocacy Forum for Tobacco Control

(India) BATA Bangladesh Anti‐Tobacco Alliance

(Bangladesh) CPAA Cancer Patients Aid Association (India) DPRK Democratic People’s Republic of Korea ERA Environmental Rights Action/Friends of

the Earth (Nigeria) FCA Framework Convention Alliance FCTC Framework Convention on Tobacco

Control HBV HealthBridge Viet Nam INB Inter‐Negotiation Body (international

government negotiations of the FCTC) ISM Inter‐Sessional Meeting (regional

government negotiations for the FCTC) IT Information Technology IUHPE International Union for Health

Promotion and Education NATT Network for Accountability of Tobacco

Transnationals NCD Non‐communicable Disease NGO Non‐governmental Organisation NHA Nigeria Heart Foundation (Nigeria) NTCA Nigeria Tobacco Control Alliance

OTAF lʹObservatoire du tabac de lʹAfrique Francophone

PC PATH Canada RECPHEC Resource Centre for Primary Health

Care (Nepal) S2S South to South SEATCA South East Asia Tobacco Control

Alliance TC Tobacco Control VCHS Viet Nam Committee on Smoking or

Health (Viet Nam) VHTU Viet Nam Health Trade Union VINACOSH Viet Nam Committee for Smoking

and Health (Viet Nam) WBB Work for a Better Bangladesh

(Bangladesh) WCTOH World Conference on Tobacco or

Health WHO‐SEARO World Health Organisation,

South East Asia Regional Office WNTD World No Tobacco Day

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ACKNOWLEDGEMENTS

Ottawa, February 2007

The South‐to‐South Collaboration and Capacity Building for International Tobacco Control project (S2S) would not have been successful without the extraordinary contributions of our partners: Saifuddin Ahmed (Mahbub), Syed Mahbubul Alam (Tahin), Annonya Rahman, and Hamidul Islam Hillol at WBB in Bangladesh, Shoba John at HealthBridge in India, Shanta Lall Mulmi and Reetu Pradhan at RECPHEC in Nepal, Inoussa Saouna at SOS‐Tabagisme in Niger, Akinbode Oluwafemi at ERA in Nigeria, and Pham Thi Hoang Anh, Nguyen Thi Hoai An, and Tran Thi Thieu Khanh Ha at HealthBridge in Vietnam. Paula Johns in Brazil, Ehsan Latif in Pakistan, Laura Salgado in Honduras, Sri Utari Setyawati in Indonesia, and far more others than we can name here also contributed significantly to the many achievements of S2S. Our numerous colleagues and friends around the world generously shared information, ideas, and experience.

This project would not have been possible without the financial support provided by the Canadian Partnership Branch of the Canadian International Development Agency.

Sincerely,

Sian FitzGerald.......................................Lori Jones Debra Efroymson Executive Director .................................Director of Special Projects Regional Director

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Figure 1 HealthBridge S2S Partners

S2S Partners

S2S Partners

S2S Partners

Original S2S Partners Additional S2S Partners


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1 Introduction HealthBridge’s recently completed project, South‐to‐South Collaboration and Capacity Building for International Tobacco Control (S2S), was designed to build local capacity for the development and implementation of key tobacco control policies, research, and programmes. This final report provides details on the activities and achievements of the project, from its beginning in June 2003 until its completion in December 2006. Originally scheduled to end in June 2006, the project received a six month no‐cost extension to enable it to complete the implementation of all scheduled activities and to take advantage of additional opportunities presented in the June‐to‐December period. This project was funded by, and acknowledges the support of, CIDA.

1.1 Canadian and Partner Organizations The South to South project was managed by HealthBridge and primarily implemented by partners in the six project countries. The partnerships developed with local partners were vital to ensure that project activities were culturally appropriate and sustainable (in Vietnam, the project was implemented by the HealthBridge local office, while in India and Bangladesh it was overseen by HealthBridge staff working locally).

1.1.1 HealthBridge – The Canadian Partner HealthBridge (formerly PATH Canada) is a non‐profit, non‐governmental organization founded in 1982 that aims to identify, understand and bridge gaps in public health, including gaps between needs and technologies, evidence and policies, and policies and practice. It works with local partners to design and implement projects to adapt practices and technologies to specific social, cultural and resource settings. Its areas of expertise include food and nutrition, malaria, reproductive health including HIV/AIDS, tobacco control, and Ecocities. HealthBridge has experience in more than 30 countries; it is headquartered in Canada with on‐site representation in Bangladesh, Vietnam and India.

HealthBridge has more than 10 years of experience working in tobacco control. It has worked since 1995 on tobacco control with Vietnamese NGOs and the Government of Vietnam, since 1998 with local NGOs in Bangladesh, and since 2001 in India and Nepal. It also has informal partnerships in Asia, Africa (Francophone and Anglophone), and Latin America. HealthBridge has developed materials that are used by NGOs throughout the world and has brought worldwide attention the issue of tobacco and poverty (Tobacco and Poverty: Observations from India and Bangladesh). It supported the activities of the Framework Convention Alliance (FCA) at Inter‐Negotiation Bodies in Geneva through the FCA Bulletin and leadership in South/Southeast Asia lobbying; it is also actively involved in the Southeast Asia Tobacco Control Alliance, providing trainers/speakers to several of its regional workshops and conferences, and being part of its core group (through HealthBridge’s Vietnam office). HealthBridge is recognized as the lead international organization supporting tobacco control at the grassroots level in low‐income countries, and has received World Health Organization awards for its work.


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1.1.2 The Local Partners Bangladesh

HealthBridge helped found Work for a Better Bangladesh (WBB Trust) in 1998, and has worked closely with it since. The two organizations have jointly implemented programmes on tobacco control and gender (both with funding

from CIDA), and began working together on transport issues in 2004. Some of WBB’s tobacco‐related successes include: an increase in the number of organizations and number of places (outside Dhaka) working on tobacco control; increased quality and quantity of tobacco control reporting in media (more frequent and extensive coverage, a broader range of issues); increased importance given to tobacco control by government, not just to World No Tobacco Day or mass education; increased quality and quantity of information available on tobacco control (research and reports) and seminars; increased participation by Bangladesh in international networks, and recognition of Bangladesh’s achievements; and a change in the public’s information, awareness, and support for tobacco control. WBB has also received small grants from the American Cancer Society, UICC, RITC and the WHO. Recently, the WHO has requested WBB to elaborate a case study on alternatives to tobacco farming for discussion at an international governmental meeting on the issue of meeting FCTC requirements to help farmers switch to alternate crops.

India HealthBridge began working in India in November 2001, with the hiring of Shoba John as Tobacco Control Advisor. Ms. John is based in Mumbai at the Cancer Patients Aid Association (CPAA). Her work consists mainly of supporting local

initiatives in policy development and media advocacy, including supporting the government in its policy initiatives. She also contributed to the creation of the Indian Coalition for Tobacco Control (ICTC). HealthBridge carried out a research study describing the economic consequences of tobacco employment to those engaged in various sectors of tobacco production in India. The report involved a survey exploring the economic consequences of tobacco use on the street children and pavement dwellers of Mumbai. The report “Tobacco & Poverty: Observations from India and Bangladesh” was widely distributed at the 5th Negotiating meeting on the FCTC where delegates from over 150 countries were present. The report was also presented at the 3rd International Conference on Smokeless Tobacco in Stockholm, Sweden in September 2002. HealthBridge served (and continues to serve) as the South East Asia Regional Contact for the Framework Convention Alliance, an international alliance formed to strengthen the FCTC. In this capacity, it worked to mobilize more organizations and advocates from the region to seriously address FCTC and domestic tobacco control policies. Ms. John was actively engaged in the negotiations on the Framework Convention on Tobacco Control (FCTC) at the national, regional and global levels.

Nepal HealthBridge has been supporting the Resource Centre for Primary Health Care’s (RECPHEC) tobacco control work since November 2001. RECPHEC’s work has focused on capacity building of government officials to better understand the policies needed to reduce tobacco use in Nepal, particularly among women, who have a high


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smoking rate. RECPHEC’s Executive Director, Mr. Shanta Lall Mulmi, attended INB5 as the civil society delegate from Nepal, and RECPHEC is working toward providing ongoing technical input to the government regarding tobacco‐related issues, and lobbying for strong and consistent support from the Nepal government in regards to this matter. For the year prior to the commencement of the S2S programme, RECPHEC had been advocating very strongly to the Nepal government on tobacco‐related issues. In August 2002, RECPHEC organized a workshop to draft a new Tobacco Control Act for Nepal, and also to incorporate FCTC principles into the constitution. Large numbers of government delegates, media personnel and NGO representatives attended this meeting, the output of which was increased commitment by the government to seriously attend to tobacco‐related issues in Nepal.

Niger L’ONG SOS Tabagisme‐Niger naquit en 1999 avait comme l’objectif principal la lutte contre le tabac au Niger. Dès sa création, SOS Tabagisme‐Niger sʹétait engagée non seulement dans une campagne médiatique contre le tabac mais aussi dans des

tournées de sensibilisation et des actions en justice contre les compagnies du tabac. Sur le plan régional, SOS Tabagisme‐Niger a pris une part active dans la création de lʹObservatoire du Tabac en Afrique Francophone (OTAF). Il sʹagit dʹun réseau dʹONG qui a pour mission de recueillir, de traiter et de diffuser des informations sur tous les aspects du tabac afin de susciter et de soutenir des actions de santé publique. Alors, par reconnaissance des efforts déployés par SOS Tabagisme‐Niger, elle a eu lʹhonneur dʹabriter le siège qui se trouve actuellement à Niamey. Il faut aussi retenir que SOS Tabagisme‐Niger dans le cadre de son partenariat avec le HealthBridge a réalisé plusieurs études dont entre autre le tabac et la pauvreté et le tabac et l’emploi. D’autres études sont en cours. Aussi, plusieurs documents écrits en anglais ont été traduits sans compter de nombreux rapports réalisés pour l’OMS dans le cadre de l’initiative dénommée «Best practices». Le président de SOS Tabagisme‐Niger, M. Inoussa Saouna, a eu une distinction de l’OMS en 2004.

Nigeria Environmental Rights Action (ERA) has long been involved in tobacco control advocacy efforts in Nigeria and internationally. HealthBridge began supporting ERA in December 2002. ERA’s activities are focused on media advocacy (press

briefings, press statements, visits to media houses, interviews and participation in radio programmes, a media roundtable on the FCTC), capacity building of media practitioners and government officials on tobacco control policy issues and coalition building among Nigeria’s anti‐tobacco groups. ERA’s efforts in tobacco control not only support the protection of the nearly 130 million inhabitants of Nigeria, but also influence the tobacco control policy situation in neighboring countries, given Nigeria’s strong political influence on the region.

Vietnam HealthBridge has had a presence in Vietnam since 1995 and has worked in the areas of tobacco control, reproductive health, and nutrition. HealthBridge is the only NGO in Vietnam to make tobacco control and prevention a programmatic

focus. Central to its mission is responsiveness to the training and technical needs of government, local non‐governmental agencies, and community coalitions. Since 1995,


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HealthBridge has worked consistently to increase national and donor support and awareness of the tobacco epidemic in Vietnam. In doing so, it has worked with many key agencies, such as VINACOSH, WHO WPRO, UNICEF, Institute for Sociology, Southeast Asia Alliance for Tobacco Control, and the Research and Training Center for Community Development. HealthBridge has also partnered with the Thai Nguyen Health Department and the Thai Nguyen Peopleʹs Committee to implement the Community‐Based Tobacco Control Project.

1.2 Goals and Objectives The S2S project’s overriding goal was to reduce tobacco use and the detrimental consequences of its use on health, poverty, and the environment in low‐income countries ‐ specifically Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam ‐ by strengthening the countries’ capacity to develop and implement key tobacco control policies (smoking restrictions, warnings on tobacco products, bans on tobacco advertising and promotion, and higher tobacco taxes), research, and programmes.

This approach comprised three Strategic Objectives:

1. Strengthen key tobacco control policies in six countries by building capacity of Southern partners to advocate for these policies and to engage in effective tobacco control measures;

2. Strengthen South‐to‐South collaboration and networking; and 3. Build public knowledge and support for tobacco control policies.

All project activities were designed to meet these goals and objectives. Section 3 of this report provides a detailed description of the project’s activities, while Section 4 discusses the progress achieved in realizing the project’s anticipated outputs, outcomes, and results. Before describing the results that were achieved, however, it is important to first understand the context within which this project was designed and implemented (Section 2).

1.3 Overview of Key Project Successes Ratification of the FCTC by all six core countries;

Development and passage of comprehensive tobacco control legislation by four of the partner countries (Bangladesh, India, Niger and Nigeria)

Contribution to global research on the critical association between tobacco and poverty.

Substantial increases in the quality and quantity of news coverage (electronic and print) of tobacco control issues, with a focus on the need for laws and law enforcement;

Widening of NGO networks to work on tobacco control and capacity building of network members to engage in policy‐related work, with all six countries creating or strengthening extensive networks to advocate for tobacco control, with some networks including journalists and government officials;

Conducting policy‐relevant research that demonstrated, for example, strong public demand for tobacco control, and the relationship between tobacco production/use and poverty;

Strong action in Vietnam to create smoke‐free public places and to improve pack warnings, and a change in the tax system to stop taxing cheap tobacco at a lower rate.


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2 Context and Rationale

2.1 Global Tobacco Control Context Tobacco use is a growing epidemic in low‐income countries, and contributes to ill‐health, environmental destruction, and poverty. The World Health Organization prioritized tobacco control in the late 1990s and early 2000, leading to increases in government involvement, especially in collaboration towards the elaboration, signing and ratification of the first international treaty specifically addressing a public health issue, the Framework Convention on Tobacco Control (FCTC). According to the WHO, “Tobacco consumption is increasing all over the world and will kill 8.4 million people a year by the year 2020 if drastic control measures are not put into effect. One in two of todayʹs young smokers will die from tobacco‐related causes. The developing countries will bear the brunt of the death toll, accounting for over 70 percent of the projected deaths.”

Tobacco is used mostly by the poor, and further worsens their economic conditions. Previous HealthBridge research suggests that over 10.5 million children currently going hungry in Bangladesh would have enough to eat if their parents redirected only a portion of their spending on tobacco to food. Tobacco cultivation is disastrous for the environment, accounting for about 30 percent of annual deforestation in Bangladesh. Many of those employed by the bidi industry are children and women, working under what amounts to conditions of slavery, for the profits of a few corporations. HealthBridge’s research on the situation of farmers suggests that this is yet another group being exploited by the tobacco industry. In short, reduction in tobacco use could have the following significant effects on poverty and the environment, and for the status of women and children: • improve the situation of poor women and children, whose access to food is hampered by

the tobacco expenditures of men who control household income; • decrease the rate of deforestation, as fewer trees are cut down to make space to grow and to

provide wood to cure tobacco; and • create alternate sources of employment (from a shift in spending from tobacco to other

products) which could lead to better jobs for the poor.

Current investments in tobacco control programmes can have a large payoff in later savings in health care costs. The health effects of tobacco use include the respiratory illnesses suffered by passive smokers (mostly women and children) as well as cancer, heart disease, and stroke suffered by active smokers, and the oral cancers caused by smokeless tobacco use (a particularly big problem in South Asia). While Bangladesh and most other low‐income countries currently spend very little on health care, those figures will increase as the economies improve. As it takes many years for tobacco‐related illnesses to develop, an attempt to reduce future expenditures on those illnesses needs to start a few decades before those expenditures become significant. Further, WHO research in Bangladesh indicates that already, health care costs for tobacco exceed the economic benefits of tobacco production.

Tobacco is unique in that much of the problem is generated by an industry ‐ that is, the tobacco companies are themselves the vectors of the disease ‐ and that relatively simple actions such as passing and enforcing national tobacco control legislation have a tremendous positive public


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health impact. The tobacco industry is extremely strong, powerful, and well‐organized. In comparison, the tobacco control movement lacks human and financial resources. The capacity of NGOs and government officials in developing countries to address the tobacco epidemic needs strengthening, with successful NGOs sharing their experience locally and internationally to enhance the capacity of others. Financial support is needed to enhance capacity building and the ability of NGOs to utilize and benefit from the lessons learned. Such an approach would

also address issues of good governance: NGOs working closely with, and supporting, governments to fulfill their responsibilities to their citizens, not to the tobacco industry.

2.2 Selection of S2S Partner Countries Partner countries were selected for this programme on the basis of the following factors: • Extreme poverty among a large portion of the population; • Opportunity to have a strong impact on tobacco control at low cost, given current low level

of investment in tobacco control(particularly true of Nepal, Niger, and Nigeria); • Access to large populations (Bangladesh, India, Nigeria, and Vietnam); • Ability to contribute regionally as well as locally (influence of S.O.S. Tabagisme – Niger on

other countries in West Africa, and of WBB and Shoba John in South Asia); • High prevalence of tobacco use and/or production; • Chance to build on lessons learned from earlier HealthBridge‐implemented tobacco control

projects or activities in all six countries; and • Existence of strong individuals and/or organizations with the ability to contribute to

capacity building in tobacco control for local government staff and NGOs.

Table 1 Selection of Partner Countries

Country1 Pop. (mill-ions)

Adult smoking

(both sexes) (%)

M adult (%)

F adult (%)

Youth smoking,

both sexes (%)

M youth

(%)

F youth

(%)

Passive smoke*

(%)

Cig cons.**

Bangladesh 137.4 38.7 53.6 23.8 - - - - 245 India 1,008.9 16.0 29.4 2.5 34.3 129 Nepal 23.0 38.5 48.0 29.0 7.8 12.0 6.0 37.8 619 Niger 10.8 - - - - - - - - Nigeria 113.8 8.6 15.4 1.7 18.1 22.0 16.0 34.3 189 Vietnam 78.1 27.1 50.7 3.5 - - - - 1025 * “Passive smoke” refers to the percent of youth exposed to passive smoking in the home. ** “Cig. cons.” is the average number of cigarettes consumed per person annually. Given the poverty of the countries, the numbers are quite low, but are likely to increase significantly as incomes rise.

1 Dr. Judith Mackay and Dr. Michael Eriksen, The Tobacco Atlas. World Health Organization 2002.


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2.3 Political Context of Tobacco Control The political situation with regard to tobacco control for each country included in this project was (and continues to be) different from each other, and as such each started the project from a different vantage point. Vietnam was the most advanced in terms of national policy, with strong laws banning advertising and a policy to reduce smoking in public, but there had been difficulties with implementation, weak warnings on tobacco packs, and a weak and inconsistent tax policy that taxed unfiltered cigarettes at a much lower rate than filtered (which kept cigarettes affordable to the poor). Since the government had demonstrated a commitment to tobacco control, however, and since HealthBridge had been working with the Government on tobacco control since 1995, there was vast potential move forward on early successes. Vietnam had the governmental and social infrastructure to support strong tobacco control policies, but government staff lacked both an understanding of potential tasks and the skills to implement them. There was also a lack of resources to train existing staff and to test strategies to determine effectiveness for implementation at a local level. An earlier CIDA‐funded HealthBridge project in Vietnam developed a strategic plan to address the requirements of the Government Resolution and to address these needs. The S2S programme focused on strengthening the implementation of specific priority policies (cessation programmes and smoke‐free areas) and building the technical capacity of local governments and community organizations to sustain long‐term operation and maintenance of the National Tobacco Control Programme.

The government of Bangladesh had also been fairly supportive of tobacco control; for example, a tobacco control law was placed before Parliament prior to the commencement of the S2S project. Getting the law drafted and placed before Parliament required a huge advocacy effort by tobacco control groups, led by Work for a Better Bangladesh (WBB) and other Bangladesh Anti‐Tobacco Alliance (BATA) members, with strong support from HealthBridge. Sustained and intensive support for government action was perceived as crucial to the development of strong laws and good enforcement, while neglect of tobacco control would likely lead to weak and/or un‐enforced laws.

As the S2S project was being designed, it appeared that in Nepal a fairly small effort would be sufficient to advance the tobacco control agenda tremendously. The government at that time was not averse to positive change, and HealthBridge’s partner organization, RECPHEC, had experienced success in getting tobacco control onto the government’s agenda. However, the Nepali political situation quickly changed early in 2004. The lack of representative governance and an ongoing conflict situation resulted in intervention by the security forces and the imposition of a state of emergency. Arrests and detention of political party leaders, massive violation of human rights, limited communication access to the general public, and the banning of advocacy and lobbying activities hindered tobacco control activities at the national level. However, working to build support for tobacco control at the community level remained viable and became the focus of the S2S project in Nepal.

In India, although the government was taking a strong regional position supporting the FCTC, and a draft law awaited vetting in Parliament, the country had in fact not yet ratified the FCTC


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and interference by the tobacco industry delayed the completion of the regulations to implement the law. Ahead of the law implementation start date of April 2004, tobacco companies engaged in logo advertising and brand stretching, familiarizing consumers with their image. Smoking in public places was the norm, rather than an exception. Beedis and chewing tobacco products carried insignificant or no taxes, while cigarette smoking was increasing. Tobacco packages carried ambiguous text warnings, which failed to convey the real risks from tobacco use. The tobacco control community was just emerging as a coherent movement, and its reach was limited to four of the then thirty‐one states in India.

Tobacco control was relatively new in Africa, and received almost no funding or international support. It was believed that relatively small investments would make a big difference, especially as most African governments had taken a strong stance in support of the FCTC and would be willing to make national improvements as well. Africa has continued to be one of the tobacco companies’ targets, yet the smoking rates in most countries were still fairly low. African countries were thus in a unique position to learn the lessons of other low‐income countries in preventing the spread of tobacco use before an epidemic of tobacco‐related disease occurred.

Tobacco control was extremely weak throughout most of Latin America. Almost no NGOs in the region were working on tobacco control. The lack of availability of useful documents in Spanish (and Portuguese) hindered their ability to move forward, and as such, HealthBridge was well placed to address that gap.

2.4 Donor Landscape Supporting Tobacco Control in S2S Countries Prior to the S2S programme, WBB had received a seed grant from the American Cancer Society in 2000 to hold capacity building workshops throughout the country, and a small grant in November 2002 from the WHO to work with media on the FCTC. HealthBridge projects in Vietnam had been supported by Research for International Tobacco Control (RITC) and WHO to undertake research on tobacco and poverty, and to train the media on tobacco control issues. HealthBridge in India had also received a small WHO grant in November 2002, to engage in capacity building efforts for local NGOs. CIDA had also provided grants for projects in Bangladesh and Vietnam, while HealthBridge provided its own funds to support small projects in India, Nepal, and Niger.

Since the S2S programme began, a number of other organizations have been funding tobacco control work in the S2S project countries, including the Rockefeller Foundation and Atlantic Philanthropies, the International Union for Cancer Control (UICC), and the WHO through its Channeling the Outrage program. Fortuitously, as S2S comes to a close, the Bloomberg Foundatin announced the release of US$125 million for tobacco control in low‐ and medium‐income countries, with priority countries including Brazil, Bangladesh, India and Indonesia (all of which were key partners or had been supported through S2S). Those responsible for the Bloomberg grants have informed HealthBridge that its partners are very likely to receive grants under the program. Undeniably, the experience partners have gained under the S2S program is critical for developing the reputation which will put them in a strong position to gain continued funding from other sources.


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HealthBridge is part of various international networks on tobacco control, including the Framework Convention Alliance, Global Partnerships for Tobacco Control, and the International Agency for Tobacco or Health. All these groups use its materials and distribute them to their members worldwide.

2.5 Rationale for the S2S Project Tobacco control is an enormous problem throughout the world, but resources for its control are generally focused in the wealthiest countries, with very little available for the rest of the world. In order to continuously broaden its market, the industry specifically targets women and youth, and carries on practices in low‐income countries that are banned or would be widely condemned as grossly unethical (such as claiming that cigarettes do not harm the health) in high‐income countries.

South Asia, with over a billion people in India alone, represents a significant portion of the world population. South Asia has very low literacy rates (particularly among women), extreme gender inequality, and high rates of tobacco use. Latin America and francophone Africa represent smaller portions of the world’s population, but also suffer from similar problems as South Asia. While there are some dedicated NGOs in Africa working on tobacco control, they have access to very limited funds to support their work. In Latin America, very few NGOs work in tobacco control. Unless serious and sustained effort is given to tobacco control, the death toll from tobacco will continue to escalate significantly in the low‐income countries for decades to come, with deaths from tobacco replacing those from infectious disease.

HealthBridge believed that a programme approach to tobacco control, building upon the success of current and past projects, would prove more efficient in terms of sharing knowledge and experience, and thus increasing the chances of successful work at low cost. Extensive South‐to‐South collaboration and networking, and enhancement of the materials available in different languages, would mean that low‐income countries could learn directly from each other and more readily gain access to appropriate technical assistance.

The S2S programme was also designed with the understanding that as it was being developed, the opportunity for making an impact in tobacco control was greater than ever before, thanks to the international attention devoted to national government‐level negotiations on a treaty specifically on tobacco control (and in fact the first treaty ever specifically on public health). The treaty, called the Framework Convention on Tobacco Control (FCTC), involved the collaboration of most of the world’s governments, under the auspices of the World Health Organization. The treaty was finalized in May 2003, just prior to the official beginning of the S2S programme; project activities were therefore extremely timely for working in partner countries to facilitate the signing and ratification of the FCTC, as well as the design and implementation of resulting tobacco control laws. The S2S programme therefore was designed to meet a real need at the time most appropriate to address that need.


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3 Overview of the South to South (S2S) Programme

3.1 Introduction The S2S programme was designed to build local capacity for the development and implementation of key tobacco control policies, research, and programmes. The six partner countries (Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam) are geographically, linguistically, and culturally diverse, but also had certain key points in common before the project began: all had strong tobacco control advocates working under difficult circumstances with a limited budget, but none had strong tobacco control laws in place. The programme built on years of collaboration with the partners, and with three years of guaranteed support, also sought to vastly expand networks in each country and strengthen existing programmes.

In five of the countries, the programme’s main goal was to strengthen tobacco control laws and policies through collaboration with national and in some cases local government. In Vietnam, the programme focused on implementing the government directive making hospitals smoke‐free. The different focus in Vietnam was due to a number of factors, including the facts that the government had already banned virtually all tobacco promotion, that HealthBridge had other funding to support the government, and that the government was having a difficult time working on the problem of secondhand smoking, with even the

“easiest” step, that of making health facilities smoke‐free, proving impossible to implement.

In addition to the six partner countries, HealthBridge used funds within the programme to support activities in other countries, including workshops in Anglophone and Francophone Africa organized by the Framework Convention Alliance (FCA ‐ an alliance of NGOs supporting the ratification and implementation of the WHO’s Framework Convention on Tobacco Control (FCTC)), and work on policy and law implementation in Brazil, Honduras, Indonesia, Pakistan and the Philippines.

The main activity groups were divided into seven distinct yet complementary, inter‐dependent and often concurrent components, each of which contributed to the achievement of the project’s anticipated outputs and outcomes: A) Research; B) Media Engagement; C) Government Support; D) Capacity Building and Technical Assistance; E) Networking; F) Public Education; and G) Project Management (Figure 2).

During its support for and implementation of each project component, HealthBridge utilized an approach that focused on working directly with key advocates who have strong skills, and providing them with modest but steady technical and financial support. The security of established funding for operational costs allowed these experts to focus their efforts on the work itself, rather than on constantly seeking funding or carrying out tangential projects that


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may have covered core expenses. Being able to access technical and financial support for research and advocacy, media engagement and government support, in a timely and flexible manner, has allowed HealthBridge’s partners to act when action is needed, and therefore to have a meaningful impact in their countries.

Appendix A reflects the CPB Project Planning Sheet and provides a summary of the planned activities outlined in the S2S programme proposal and how they related to the proposed outputs, outcomes and impacts of the programme. As noted in the sections that follow, the project’s implementation followed the proposed plan quite closely, with additional activities being added as opportunities were presented. For example, the original proposal contained no plans for supporting activities in countries beyond the original six; however, as the project progressed it became evident that this would be extremely beneficial in achieving the goals and objectives of the project on a broader scale and, with CIDA support, was therefore incorporated into the programme activities.

The components described in the following sections are linked to the CPB planning sheet activities by placing the activity group number (as in Appendix A) in parenthesis following the description of the component. The section on “Results: Goal Achievement” (Section 4) discusses how these components have resulted in the achievement of the planned outcomes and impacts. Also included in Section 4 is a timeline of key successes and results achieved. Details on activities and results by country (rather than by component) are found in Appendix 2.

Figure 2: Overview of S2S Programme Components

Component D: Capacity Building

and Technical Assistance

S2S Programme

Component A: Research

Component B: Media

Engagement

Component C: Government

Support

Component E: Networking

Component F: Public Education

Component G: Project Management

FCTC Ratification Strengthened tobacco control legislation & policy International recognition Strengthened collaboration Increased public support for tobacco control


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3.2 Component A: Research While a lot of research already exists about the deadly harm ‐ to health, environment, and individual and national economies ‐ caused by tobacco, this research has not necessarily been directed at achieving changes to, or creating, tobacco control policy. Research for advocacy, on the other hand, seeks to provide specific evidence of the need for a certain policy or programme, or to demonstrate that a certain government action will prove popular. While existing research results can often be used for advocacy purposes, in cases such as tobacco control, country‐specific research is often required to convince a particular government of the need for change. Similarly, where arguments against policy change are symbolic rather than legitimate, the need is not necessarily for information that will change people’s minds, but rather for a convincing document that will challenge false arguments. Sometimes all that is needed is an opinion poll, or a collection of case studies on how people have thrived since shifting their livelihood from tobacco to other sources of income. The S2S programme therefore provided funding for HealthBridge’s local partners to undertake country‐specific and targeted research to lay the groundwork for local tobacco control advocacy and public education (Activity Group 3). Examples and highlights from the partner countries are noted below.

3.2.1 Niger: Researching the impact of tobacco use on poverty and employment SOS Tabagisme‐Niger conducted two research projects, one on how tobacco use further increases poverty, and one on the limited benefits of tobacco‐related employment. Publication and distribution of the reports proved critical in gaining new allies to tobacco control, in demonstrating the importance of tobacco control in poverty‐struck Niger, and advancing the ratification of the FCTC and passage of a tobacco control law. The reports also served well to counter objections made by the tobacco industry that the industry was economically important for the country. Finally, the research reports gave advocates the information that they needed to demonstrate that while the tobacco industry enriched certain individuals, it actually contributed to impoverishing the nation as a whole.

3.2.2 Action research in Nepal: Collaborating with Tribhuvan University RECPHEC in Nepal demonstrated how an NGO with limited experience in research could effectively conduct quality research to contribute to its advocacy campaigns. RECPHEC partnered with the Padma Kanya Campus of Tribhuvan University on several research programmes. A total of eight field studies were conducted by university students of the Womenʹs Studies Programme on different dimensions of tobacco, including (i) prevalence of tobacco use, (ii) tobacco consumption by women and its impact on their reproductive health, their children’s birth weight, and infant mortality, (iii) the impact of media on tobacco use, (iv) economic and social impact of smoking, and (v) perception of girls towards tobacco use. The research programme, in addition to providing important information for RECPHEC’s advocacy campaign, also served to help train young women in conducting research. Partnering with a university is in fact an innovative and cost‐effective way of conducting quality research while limited funds and expertise.


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3.2.3 Bangladesh: Tobacco taxes and the poor HealthBridge and WBB Trust provided extensive technical assistance to a member organization, Manobik, of the Bangladesh Anti‐Tobacco Alliance (BATA), to develop a proposal and carry out a research project on the likely effects on the poor of raising tobacco taxes. Manobik’s proposal was funded by the Government of Bangladesh, which meant that the research results were more likely to be used by the government than if the research funding had come from elsewhere. (Manobik had previously successfully lobbied the government to include tobacco control issues in its list of programmes for which it provides research funding.)

The research included a survey of 1,000 low‐income tobacco users, both male and female, and individual interviews and focus group discussions with the poor (tobacco users and non‐users) and with members of civil society (professors, government officials, NGO workers, etc.). The questions included whether people considered that it was more important to keep taxes low on tobacco or on other products (such as bicycles); how low‐income tobacco users would be likely to respond to a tax increase; whether tobacco users would like to see their children take up smoking; and whether the poor could be helped in a more useful way than through subsidizing tobacco by maintaining low taxes. The research yielded extremely useful information, as well as revealing great support for increases in tobacco taxes.

3.2.4 Vietnam: Research for evaluation and for policy In order to evaluate the effectiveness of its programme that focused on smoke‐free health facilities, HealthBridge conducted both a baseline and a post‐intervention survey on a sample of hospitals to investigate the level of and barriers to implementation of smoke‐free hospital policies. Survey questions examined doctors’ and hospital staff’s attitudes and knowledge. The questions were complemented by direct observation of the presence of no‐smoking signs and of compliance or violation of the smoking bans. HealthBridge Vietnam (HBV) also contributed to international understanding of the relationship between tobacco and poverty through a research programme supported in part by Research for International Tobacco Control (RITC) and further supplemented by the Rockefeller Foundation/Atlantic Philanthropy. By adding a few questions on tobacco use to a much larger survey on children’s well‐being, HBV was able, at relatively small expense, to obtain an enormous database of information showing the differences in expenditures on education and food between tobacco using and non‐using families. HBV also conducted research, at the behest of the Vietnamese government, on pack warnings in order to gain information on what sort of warnings people would find useful. The research was of great use in HBV’s campaign for stronger, pictorial warnings on cigarette packs.

3.2.5 Pakistan: Analyzing policy implementation weaknesses In Pakistan, the S2S programme supported the study “Implementing Anti‐Tobacco Statutes in Pakistan: A developing country perspective.” This analysis tackled the issue of implementing statutes linked to tobacco control in a developing country like Pakistan where adoption of legislation is not directly linked to its implementation. Though the statutes adopted by the legislature of these countries conform to various provisions and clauses of FCTC, the implementation mechanisms for them remain a


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challenge. One of the reasons commonly cited for non‐implementation is the deficient infrastructure and lack of resources; therefore even after the adoption of various policies and signing of treaties, the governments may not have the capacity to implement laws pertaining to tobacco consumption in a manner that could ensure a decrease in tobacco consumption. The study’s final report sought to share experiences and recommended certain steps which, if followed, could assist in effective implementation mechanisms for tobacco control.

3.2.6 Philippines: Assessing public knowledge of existing tobacco control ordinances In the Philippines, the S2S programme supported a survey that sought to evaluate the level of public awareness regarding existing tobacco control laws in that country and support for such laws. The survey also developed a profile of smokers in the surveyed areas (Quezon City, Metro Manila and one city in Bulacan province). The survey results demonstrated that 14% of current smokers were legally considered to be minors (18 years old and below). Of the adult smokers, 25% were unemployed, and of those, 40% were married and had a family. This led the researchers to question, “Where did the smokers get the money to feed their addiction?” Meanwhile, 63% of those interviewed were unaware of any tobacco control measures implemented by the government (local, provincial or national). This was considered to be a substantially high percentage, considering that a number of tobacco control laws had been enacted and programs implemented by the government over the previous 10 years. Eighty percent of the non‐smoking survey respondents indicated that they would be in favor of a public smoking ban, citing it as a good measure to control smoking; 70% of the smoking survey respondents also supported a public ban. At the same time, only slightly more than half of the respondents (54% of smoking and 38% of non‐smoking) supported the idea of increasing tobacco taxes and prices, feeling that it would affect their budget as well as the prices of other consumer goods.

3.3 Component B: Media Engagement The media is an extremely powerful tool for reaching governments and the general public to work for change. Government officials watch TV, listen to the radio, and read the newspapers. Media helps government officials understand what issues are “hot” and need to be addressed. Media coverage also encourages the general public to recognize important issues. To raise awareness of tobacco control issues, those issues must be in the news. To do this, the S2S programme worked to get journalists’ attention, understand what they want, and make its issues newsworthy. Partners in the S2S network quickly became media experts, or further enhanced existing expertise. (Activity Group 3)

HealthBridge published Using Media and Research for Advocacy: Low Cost Ways to Increase Success, combining two previous guides. While the previous guides had focused exclusively on tobacco control, the revised version also incorporated lessons from other programmes, including car control and promotion of fuel‐free transport, gender, human rights, and the environment. Given

Impressions: “Reading the results of your research on tobacco and poverty has inspired us. If the study logistics are affordable, Iʹm sure that lots of countries ‐ developed, transitional, and developing ‐ would like to participate!” – Anonymous comment


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that many people working internationally on tobacco control are not native English speakers, HealthBridge prepared the popular guide using plain, simple language and offered colourful illustrations from throughout the world of low‐budget, successful activities.

3.3.1 Brazil and Indonesia: Using the media to move a reluctant government Brazil faced one of the more difficult battles in getting the FCTC ratified and, as in so many other countries, discovered that the media is often critical in moving reluctant governments. HealthBridge supported REDEH ‐ Rede de Desenvolvimento Humano ‐ and the Tobacco Zero Network to conduct a press conference inside the national Congress about government support for the FCTC. All 81 senators had been asked in advance whether they were in favor of or against the FCTC ratification. Since only 24 responded positively, the project team decided to “turn the whole idea upside down” and wrote a press release saying that Brazil had only 24 senators committed to public health. The press release got excellent results, with the main Brazilian papers covering it, and “things started moving faster after that”—eventually leading to FCTC ratification.

To bring even more attention to their cause, Dr. Nise Yamaguchi, an oncologist and President of NAPACAN (a support group for cancer patients), arranged for actors to visit Congress dressed up as a cigarette pack, a seductive cigarette lady, and a lung chained by the cigarette lady, named Ms. Nicotine. Together they went to the media area between the Chamber of Deputies and the Senate. On that day there was a huge scandal as the President of the lower chamber was being impeached; the colorful outfits got the media’s attention—thus

bringing their attention to the FCTC as well, despite its being otherwise a very low priority.

In Indonesia, the Indonesian Forum of Parliamentarians on Population and Development (IFPPD) organized an outdoor media event and two press conferences to increase political and public awareness of the need for FCTC ratification and national law enactment. In addition to IFPPD, the media event involved 15 national organizations, all committed to tobacco control. The press conferences enabled representatives of fifteen newspapers and television and radio stations to ask questions/raise issues related to misconceptions about tobacco control, which they could then print or broadcast. Many of the issues addressed explored the reasons behind the government’s failure to ratify to the FCTC (one of only two countries) and to pass a national tobacco control law. The press conference also forced some government representatives, such as a representative of the Ministry of Health, to explain the government’s current stance on tobacco control.

3.3.2 India: Taking action against illegal advertising Indian activists noticed that a cityʹs new and trendy daily, DNA Sports, was regularly promoting the multinational tobacco brands Marlboro and Mild Seven under the guise of covering Formula One races. The activists wrote to the newspaper, drawing their attention to the fact that such coverage violated the national law, which banned promoting tobacco logos, and noted in their letters that evidence from India and abroad confirmed that exposure to tobacco sponsorship of sports increased childrenʹs experimentation with and uptake of tobacco.


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Activists waited for one month, but received no response to their correspondence. Nevertheless, they continued monitoring the paper for further violations. In the weeks following their letters, they noted that coverage of Formula One in the daily masked or erased the cigarette brand names. While there is still a long way to go to ban tobacco colours from the drivers’ uniforms and cars, the small success demonstrated that simply by alerting offenders of their violations of national law, they may voluntarily choose to comply.

3.3.3 Niger: Building on personal media relationships As with all the other partners in the S2S network, SOS Tabagisme‐Niger has maintained a close relationship with media. This relationship was perhaps facilitated by the fact that the president of the NGO, Inoussa Saouna, is himself a former radio journalist who was fired due to his outspoken stance against the activities of the tobacco transnationals. M. Saouna has from the start been active in recruiting journalists to join in his tobacco control network, so that reporters and those working on widespread issues such as consumer protection, environment, human rights and HIV/AIDS work closely together. This close relationship has helped ensure the success of their advocacy efforts, which finally resulted in Niger’s ratification of the FCTC and passage of a tobacco control bill.

3.3.4 Media advocacy in Nepal RECPHEC worked actively to form a strong media network for anti‐tobacco control work. Specifically, RECPHEC helped a group of media representatives committed to working on anti‐tobacco campaigns to form a coalition called “Media Object”. The objectives of the coalition were to raise awareness on tobacco and health, publish articles in different newspapers and magazines, and to publish analytical articles and reports on tobacco promotion and marketing. In addition, Media Object, with the support of RECPHEC, conducted a study on Smoking and Tobacco Use in Nepal.

Recognizing the importance of media for achieving government policy change, RECPHEC has consistently worked closely with different media bodies. For example, RECPHEC organized a press briefing on 27 February 2005 to inform people that the FCTC was coming into effect globally and to urge the Nepalese government to ratify the treaty as early as possible. As part of the press briefing, the Executive Director of RECPHEC, Mr. Shanta Lall Mulmi, gave a TV interview on “the FCTC and Nepal”, which was telecast in the prime news bulletin of 27 February. RECPHEC also succeeded in convincing the Ministry of Health to begin awarding journalists annually for their contribution to anti‐tobacco campaigns.

RECPHEC also gained much media coverage through its extensive district network:

Chitwan television telecast the street drama organized by the network group of Chitwan on the occasion of World No Tobacco Day.

Local FM of Banke broadcast a programme on how the Muslim community is against tobacco products. The Muslim community has agreed to make all Madrassa (religious schools) smoke‐free zones.

Kalika FM of Chitwan broadcast an interview with Mr. Shanta Lall Mulmi on the district network and its activities on tobacco control.


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Dhaulagiri FM of Baglung aired a special 30 minute interview with Mr. Shanta Lall Mulmi on 18 August 2006 during a District Tobacco Control Network meeting.

Image TV telecasted a special interview of Mr. Shanta Lall Mulmi on FCTC ratification.

In addition to district‐level media coverage, Nepal Television 2 telecasted a special thirty‐minute programme on RECPHEC’s tobacco control activities during primetime (7:30 pm) on 9 September 2006. RECPHEC has also published articles, comments and news in national daily newspapers of Nepal. RECPHEC collects press clippings of tobacco‐related news and articles from different national newspapers.

3.3.5 Bangladesh: Using the many forms of media Given the ease with which one can reach both a general audience and policymakers through the media, WBB has always placed great importance on media advocacy. Following the passage of the tobacco control law, the media increasingly covered various aspects of tobacco control, including the law itself, smoke‐free places, tax increases, activities of the tobacco industry, and other issues such as the relationships between tobacco and nutrition and tobacco and economics. WBB also addressed these issues in its press releases and media communications.

WBB maintained documentation on all tobacco‐related news items, collecting news clippings and sending them to government officials and to network members who were responsible for getting the coverage. This documentation covered much of the country, thanks to the activities of the tobacco control network members. WBB also collected international coverage and documentation of tobacco advertising and other illegal activities of the tobacco industry.

At the beginning of the project, WBB mostly focused its efforts on print media; early on, there were very few TV channels, so it took a lot of time and thought to gain their attention. Over time, however, the number of media outlets (particularly private TV channels) greatly increased, enabling WBB to make plans to increase its access to electronic media. Since it is very expensive to access electronic media through traditional channels, WBBB spent a lot of effort looking for other ways to access it. For instance, it tried to get existing programmes such as talk shows to mention tobacco control, rather than organizing its own event. WBB made TV spots and sent them to various channels to air as public service messages. As a result of its letters requesting them to air the spots, many did so. WBB also built personal relationships with various TV producers, who then invited its staff to speak in programmes on tobacco control.

WBB also sometimes sent CDs of its programmes to TV channels for airing, as well as inviting TV channels to all its organized events, such as press conferences and outdoor demonstrations. WBB provided TV journalists with information and footage when they requested it, and made special offers to journalists with whom it had particularly close relationships for exclusive information and footage. Similarly, thanks to the development of a strong personal relationship with producers at Bangladesh Betar, the national radio station, WBB now regularly organizes radio talk shows in its office, with the radio people coming to tape the programme.

Another important and often neglected medium is cable TV networks. Although the channels may be small, the population of Bangladesh is so large that they can still be used to reach tens of thousands of people. WBB provided local members of its network with TV spots, ads, and other footage to air, with the local NGOs names added to the programme to encourage them to push


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strongly, and often successfully, for the airing of the spots at minimal or no cost.

3.3.6 Nigeria: Innovative use of the media Environmental Rights Action (ERA) in Nigeria was enormously successful in generating media coverage of tobacco control issues. The success is particularly remarkable in that the media have a long history in Nigeria of being friendly to the tobacco industry, obligingly publishing their press releases while ignoring any possible opposing viewpoints. In fact, Nigeria serves as proof

that lack of media coverage is far more likely to be due to inadequacies on the part of NGO media programmes than to media bias. That is, while media houses around the world are friendly to the industry, in any country normally some will respond to news on tobacco control; what they will not necessarily publish are uninteresting articles about how tobacco harms health. By becoming experts at media advocacy, people can usually overcome the industry‐sponsored opposition of media to tobacco control coverage, and ERA has been enormously successful at doing just that. Nigeria’s media campaign generated many successes, including:

A change in reporting of tobacco issues from an industry perspective to a public health, tobacco control perspective.

Success in attracting policy makersʹ attention: Nigeria signed and ratified the FCTC. Achievement of a partial restriction of advertisement as a panicky measure from the Advertising Practitioners Council of Nigeria.

Direct responses from BAT following a trip organized by ERA for journalists to visit poverty among tobacco farmers.

A “probe” of BAT by the House of Representatives as a result of one of the trips to the farmers and the media campaign around it.

3.3.7 Vietnam: Strengthening a media network for law enforcement HealthBridge’s Vietnam tobacco control programme was fortunate in attaining synergy among several funded projects, wherein each project was able to strengthen the others. Funding from the Rockefeller Foundation allowed HealthBridge to hire a media officer who could then develop and maintain a media network. The media network meant that HealthBridge could develop close relationships with reporters of various important newspapers, who grew increasingly willing to write about tobacco control. In addition, the media officer regularly monitored media coverage for positive and negative coverage of tobacco control and for any evidence of violations of tobacco control law. In the case of violations, the media officer immediately alerted the government body for tobacco control, VINACOSH, and other responsible authorities.

HealthBridge also utilized funding from Research for International Tobacco Control (RITC) to conduct a survey with editors and reporters of newspapers to identify gaps in their awareness, attitude and perception of problems caused by smoking, tobacco control policy, and the FCTC. With the support of another small grant from the International Union for the Control of Cancer (UICC), HealthBridge developed and conducted two training workshops to address those gaps.


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The media has played an active role in supporting the HealthBridge programme for smoke‐free hospitals, frequently responding positively to information sent by the media officer on the baseline survey and project activities. In addition to print coverage, HealthBridge also worked with Vietnam TV (VTV) to develop a report on the harmful effects of passive smoking. In addition, HealthBridge developed a TV spot educating smokers not to smoke in public places including hospitals.

Media can be used to serve many purposes, as the Vietnam programme demonstrated. In order to promote the concept of smoke‐free hospitals, HealthBridge provided media with information on the project, including its success and challenges; the media in turn disseminated project information to the public. Without the use of media, it would not have been possible for HealthBridge to reach such large audiences with information about the importance of smoke‐free hospitals and the need to comply with government regulations for smoke‐free hospitals.

3.3.8 Philippines: Increasing media awareness of tobacco control The Bilin ng Mamamayang Konsyumer (BILMAKO ‐ Filipino Consumers’ Will) produced and distributed FCTC materials and fact sheets to media practitioners and establishments throughout the country to raise awareness among media personnel about tobacco control. During the time that the materials were distributed, they also monitored the media to determine if the information they had provided had any effect on tobacco control reporting. In a three month period, more than 20 news articles about tobacco issues were printed in six different publications; however, those taking a positive approach to tobacco control appeared only after the national elections (midway through the three month period). These articles addressed tobacco and sports, litigation, increasing taxation, laws against smoking, health hazards, and the dying tobacco farming industry. Over the same period, a television programmed aired a five‐minute story about victims of tobacco use; the story was based on information provided by BILMAKO. A nationwide programme was also aired on Radio Veritas, a popular radio station that was instrumental in the downfall of the Marcos regime in 1986.

3.4 Component C: Government Support Tobacco control work cannot be successful without strong collaboration between government and non‐governmental agencies. Since the most effective ways to reduce tobacco use are through laws and tax increases, government action is necessary; yet governments often require the support of NGOs to pass and enforce strong policies. In some situations a natural conflict appears to exist between GOs and NGOs, yet positive working relationships can also exist. Governments have many responsibilities, and can only afford limited effort in the field of tobacco control. Law enforcement is just one of many areas in which GO‐NGO partnerships are critical for success. The S2S programme provided opportunities for local partners to engage government officials, to build their knowledge about tobacco control, and to provide ongoing support to the development and implementation of tobacco control legislation and policy

Impressions: “HealthBridge in Vietnam has given us so much information; we have learned a lot that we didn’t know before about tobacco control. The tobacco companies surely don’t want us to have this information, but now we can write news stories that tell the truth.” – Anonymous journalist, Hanoi, Vietnam


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(Activity Group 1).

3.4.1 Vietnam: Facilitating government‐NGO collaboration Many countries have formed alliances or other groups to coordinate efforts on tobacco control. Usually such groups consist solely of NGO members. But the Tobacco Control Working Group in Vietnam has been successful at bringing together NGOs, the WHO and other UN agencies, and the Vietnam Committee on Smoking and Health (VINACOSH), the government agency responsible for tobacco control. The presence of VINACOSH in the Working Group is extremely important in ensuring communication and collaboration across sectors. HealthBridge Vietnam trained government officials to make hospitals smoke‐free in a direct collaboration with the Department of Therapy of the Ministry of Health and the Vietnam Health Trade Union. The GO‐NGO collaboration was facilitated by the fact that HealthBridge had been working with the Ministry of Health and VINACOSH for years, and that the programme directly addressed a key issue faced by the government. The Minister of Health had issued a circular on strengthening tobacco control in health facilities which required that all health facilities become smoke free. Implementation, however, was weak; both VINACOSH and the Health Trade Union were eager to improve implementation, and thus were receptive to GO‐NGO collaboration on the issue.

The collaboration was also facilitated by the fact that the main role and responsibility of the Health Trade Union is protecting the interests and benefits of health professionals, and making hospitals smoke‐free was very relevant to this function. HealthBridge’s support to the collaboration was provided in several ways: through provision of services (offering information on various tobacco control‐related topics) and materials (stickers, reports), and through friendly exchanges during informal visits that complemented more formal meetings.

HealthBridge Vietnam attempted to maintain a close relationship based on respect for a variety of opinions and approaches to work. HealthBridge worked together with government partners to develop work plans and to nurture a sense of project ownership among the partners. All training workshops were designed based on mutual agreement after discussions on the time, place, and agenda. While HealthBridge provided technical and logistical support (for instance by providing training and disseminating IEC materials), the leaders of the Health Trade Union (HTU) consistently assumed the leading role in the workshops. HealthBridge prepared drafts of IEC materials to share with the HTU, which provided feedback in their revision.

HealthBridge found that many hospital managers, if they missed the chance to attend the workshops, later contacted HealthBridge directly for the materials and technical support, and two hospitals (Hospital E and the Hospital of Traditional Medicine) organized their own workshop, asking HealthBridge to provide technical support.

3.4.2 Nigeria and Nepal: Including NGOs in government steering committees for tobacco control

Environmental Rights Action (ERA) in Nigeria championed the formation of a National Inter‐ministerial Committee on Tobacco Control. After vigorous advocacy, the committee finally received presidential approval, and asked the Programme Manager responsible for tobacco control at ERA to represent civil society on the committee. That is, not only did the S2S partner succeed in its overall goal of gaining the establishment of the committee, but through its


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advocacy efforts, the work of ERA itself was acknowledged to the extent that ERA was invited to join the committee.

RECPHEC in Nepal supported a vigorous district‐level network. One district, Nawal Parasi, conducted a successful workshop on FCTC and the Role of Civil Society that led the Local Development Officer to propose the District Health Officer as the convener of the district network, the Chief District Officer as the advisor, and the leading local NGO, SAHAMATI, as secretary. That is, local government both came to the forefront of the tobacco control network and expressed their strong interest in collaborating with NGOs.

3.4.3 Bangladesh: Supporting the role of government In the course of working on advocacy, WBB realized the importance of establishing and maintaining a strong, close, direct relationship with government. It quickly realized that simply standing back and criticizing government actions without working directly with the government to improve its policies was unlikely to result in any positive change. WBB’s close relationship with government became possible through a combination of a friendly, personal approach; provision of various forms of assistance to government; and regular communication and information sharing. It explained to government officers the importance of passing and enforcing a tobacco control law to improve health, reduce poverty, and reduce the harm to the environment caused by tobacco production and use. It shared international experiences in law enforcement. It explained about the activities of the tobacco industry, measured and shared public demand for tobacco control laws and higher tobacco taxes, and provided this information to the media.

Early on, government officials were unaware of the existence of the treaty, and Ministry of Health officials did not know the process of ratifying a treaty. There was no coordination among the various Ministries involved in the process. Since BATA members already had international experience, and the BATA coordinator attended most of the regional and international meetings (ISMs and INBs) for the FCTC, funded by WHO, BATA was in an excellent position to help government officials understand the treaty process.

WBB project staff members were very involved in drafting the tobacco control law and in supporting the government through the process of FCTC ratification. WBB also supported law implementation, including mobilizing mobile courts to take down tobacco ads, and convincing the Ministry of Health to publish notices in the newspaper to inform tobacco companies of their legal obligation to strengthen package health warnings. WBB also played a key role in negotations to establish the government’s national steering committee for tobacco control, and was given a role on the committee as an NGO representative. The Minister of Health also requested that the Bangladesh Anti‐Tobacco Alliance carry out public demonstrations in support of tobacco control policies at key points in the debate in order to demonstrate popular support for tobacco control.

In addition to the work WBB did on the law and the FCTC, it also addressed the rules to accompany and further define the law. While the tobacco control law is essentially a set of overall measures, the rules provide the main substance, and implementation of the law was not possible until the rules were passed. WBB took responsibility from the very beginning to draft a


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set of rules and participate in regular meetings to ensure their passage. Representatives of the tobacco industry regularly participated in meetings about the rules, and did their best to ensure that the rules were watered down to insignificance, but WBB’s continual efforts to counter their arguments proved successful, and a strong set of rules were finally passed.

WBB was also involved in the development of the national three‐year plan for tobacco control from the outset. It drafted, on behalf of the Ministry of Health, the proposal for the development of the plan to submit to the WHO, and drafted a sample three‐year plan. It helped to organize

workshops around the country to discuss the plan, created presentations for the workshop, trained the facilitators, collated the proceedings, and helped turn the input into a plan. WBB’s support to the government was awarded by the government’s greater willingness to cooperate on such issues as law implementation. Without WBB’s active work on behalf of the government, the government would not have been so ready to work closely with NGOs.

3.4.4 Nepal: Pressure and partnership RECPHECʹs relation with the government reflects both pressure and partnership. For years it advocated the government to pass a Tobacco Control Act and to ratify the Framework Convention on Tobacco Control. But RECPHEC’s relationship with the government was also a partnership. Government representatives participated in different meetings and workshops organized by RECPHEC, and presented papers and government strategy on tobacco control.

One of RECPHEC’s most important activities was the organization of a one‐day consultative meeting of the concerned ministries of His Majestyʹs Government to develop a consolidated and coordinated effort to respond to the FCTC, given that tobacco control could not succeed with the effort of only the Ministry of Health. This workshop was the first of its kind in Nepal, where all the concerned Ministries including Environment, Agriculture, Health, Finance, and Law and Justice presented papers on the issue. The main objective of this workshop was to encourage the government to sign the FCTC and to strengthen the network of private agencies, government, civil society and media to implement the FCTC in Nepal.

Another major step taken by RECPHEC was the production of an Advocacy Kit for Members of Parliament. The kit contained information on different health issues including tobacco, allowing RECPHEC to integrate tobacco control advocacy into other important health issues..

Following years of advocacy efforts, Nepal experienced a great success when ProPublic, which works closely with RECPHEC, filed a case with the Supreme Court for the implementation of tobacco control policies. On 15 June 2006, the Supreme Court made a landmark decision against tobacco. RECPHEC appealed to the government of Nepal to take immediate action to make the necessary arrangements in response to the Supreme Court decision.

RECPHEC consulted with the Legal Consultant of the Health Ministry on preparation of the Tobacco Control Act Draft legislation; the draft was later submitted to the Ministry. While RECPHEC also jointly organizes celebrations for World No Tobacco Day with the government, such activities represent only a small portion of total GO‐NGO collaboration in Nepal.


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3.4.5 Indonesia: Harnessing the influence of women legislators To raise awareness of the importance of tobacco control, and to strengthen the tobacco control policy environment in Indonesia, HealthBridge supported the Indonesian Forum of Parliamentarians on Population and Development (IFPPD) to undertake interactive dialogue with women parliamentarians, women senators, and their constituencies. The Women’s Parliamentarian Caucus, a women’s parliamentary movement inside the Parliament, has 63 women parliamentarians and 28 women regional representatives (senators) who could be mobilized to gain the support of their constituencies for the draft bill. The series of three dialogues involved informal presentations by regional tobacco control experts, followed by open discussion among the participants which allowed them, in many cases for the first time, to share information, dispel common myths about tobacco control, and explore innovative ways to address the issues.

3.4.6 Philippines: Advocating during political elections HealthBridge’s local partner, BILMAKO, organized a senatorial forum on behalf of the People’s Legislative Network during which it submitted PLAN’s consolidated priority legislative agenda for social development, which included FCTC ratification and implementation. The senatorial candidates from three major political parties and various NGOs signed a covenant to support PLAN’s legislative agenda at the 13th Congress. Unfortunately, the senatorial candidates who signed the covenant lost in the elections.

3.5 Component D: Capacity Building and Technical Assistance The traditional approach to tobacco control has been to educate people, often school children, about the harms of tobacco, and assume that such knowledge would be sufficient to result in behavior change. Unfortunately, international experience has shown that the extreme attractiveness and nearly universal presence of tobacco advertising, combined with the low cost and easy availability of tobacco products and the ability to smoke just about anywhere in most countries, easily overrode the messages taught in schools.

What is successful in reducing tobacco use is a comprehensive set of policies, specifically a ban on all forms of advertising and promotion, higher taxes on tobacco products, smoke‐free public places, and strong pack warnings. Such measures can be complemented by measures to reduce smuggling, to inform the public about the importance of such policies, and to target difficult‐to‐reach populations which may not be affected by national policy.

In order to increase the effectiveness of the work of local organizations and government officials on tobacco control, the S2S partners sought to share, and learn from, international lessons learned in tobacco control, in terms of what works and what does not, and how to achieve

Impressions: “WBB provided important support to the government by printing the law and accompanying rules, and sending them to officials throughout the country. WBB also helped ensure that all involved officials received letters encouraging their active participation in tobacco control law implementation. Such activities were vital to ensuring the level of awareness needed to implement the law effectively.”‐‐Kuheli Mustafa, Secretary General, WACC


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sustained reductions in tobacco use. Capacity building of key individuals to carry out effective work was thus a critical part of HealthBridge’s work (Activity Group 1).

3.5.1 Bangladesh: Building the capacity of local partners In order to ensure that its partner organizations had the skills to engage in effective tobacco control work, capacity building was a vital activity in Bangladesh. WBB’s investments in capacity building for network members paid off in terms of increased capacity of its network members and thus a stronger nationwide tobacco control programme.

WBB carried out three national and six divisional workshops. The subjects of the workshops included examining what the contents of Bangladesh’s tobacco control law should be, obstacles to its implementation, important activities to improve its implementation, raising awareness of law, what is the FCTC, why the FCTC is important and how we can work for its implementation, how to coordinate local and national activities, and monitoring of law enforcement. As a result of the workshops, network members gained significant knowledge about law development and implementation and the FCTC.

In addition to conducting workshops and distributing materials, WBB asked its partners directly what sorts of information or skills they needed to enhance the effectiveness of their work. In the first stage, WBB prepared information informally on the content of the country’s tobacco control law and sent it to its members by letter. In the second stage, WBB explained ways in which the law was being violated, and asked members to send reports on the law violation/enforcement situation in their district. In the third stage, WBB encouraged the network members to communicate with local officials to inform them about the content of the law, violations, and their role in enforcement. In the fourth stage, representatives from twelve districts particularly active in tobacco control were selected for more intensive activities in law monitoring and enforcement.

WBB also assisted NGOs with a range of other activities. It provided in‐house training support for young staff and volunteers of partner NGOs at the WBB office. Subjects include information technology, planning a project, writing a proposal, drafting a budget, report writing, documentation, internet use, media, and collaboration with other NGOs. The training was mostly hands‐on; after explaining how to do a task, the trainees were given the responsibility of carrying out the task themselves, with WBB providing support as needed. While this was very time‐intensive for WBB staff, it did result in a significant increase in skills.

3.5.2 India: Expanding the network The HealthBridge programme in India worked actively on capacity building of NGOs and government throughout the country. Specific features of HealthBridge’s NGO training programmes included efforts to address locally relevant topics such as poverty, agriculture, and marketing; involvement of local trainers in planning and in training, including tobacco control network members as speakers; ensuring that the workshops were organized by well‐known local organizations; and utilizing a participatory rather than didactic design. Among other subjects, workshops always addressed the development of a Plan of Action, and linking with additional resources. Outcomes of the training included an increase in local and national tobacco control action, and the undertaking of more watchdogs to monitor implementation of


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the national law. The HealthBridge Program Manager in India also played a key role in building capacity in Bangladesh to ratify the FCTC, when she visited Bangladesh and served as a trainer in a workshop on the subject. In the workshop, she utilized participatory methods and helped participants develop workplans focused specifically on FCTC implementation, which proved immensely helpful in the organization of partners for the ratification campaign.

3.5.3 Vietnam: Capacity building of government partners HealthBridge’s capacity building in Vietnam targeted two groups: 1) hospital managers, in order to build knowledge and skill on implementing and maintaining smoke‐free policies in hospitals, and 2) the Health Trade Union (HTU) and officers of the Department of Therapy of the Ministry of Health on how to manage and follow up implementation of smoke‐free policies in hospitals. In addition to meeting the objectives established at the beginning of the S2S programme, government teamwork and project design also improved by working with HB.

In the case of hospital managers, HealthBridge provided technical support through workshops (speaker, facilitator handouts and IEC materials). HealthBridge staff collected best practice examples in the development of smoke‐free hospitals from the Internet and available literature and then drafted guidelines for the development and criteria of smoke‐free hospitals in Vietnam. These guidelines were printed as a manual and disseminated in the workshops. Due to limited resources, the S2S project could only target central and provincial hospitals, but HealthBridge succeeded in reaching the health facilities at all levels in a further six provinces through collaboration with other programmes. In most cases, HTU monitored project activities through its regular hospital visits.

For the second target group, capacity building was achieved through the strategy of “learning by doing”. HTU were involved in all steps of project implementation, including material development. The Department of Therapy also shared the criteria they had developed for smoke‐free hospitals with the project team for comment; that is, government actively solicited NGO input into their programme.

HealthBridge discussed with HTU who would most benefit from and be able to use what they learned in the training—that is, those who had influence on hospital policy development and implementation. This collaborative process resulted in trainees representing high‐level hospital positions, such as members of the Board of Directors, President or Vice President of the Hospital Trade Union or Head Office of Medical Affairs ‐ people responsible for implementing hospital regulations and for quality of care.

The training agenda included the effects of smoking (both active and passive), the criteria of a smoke‐free hospital, and steps for making hospitals smoke‐free. One innovative technique used in the workshops was to identify hospitals with good experience in implementing the Minister’s Circular on smoke‐free hospitals, and inviting them to be speakers at the next workshop. This tactic proved extremely valuable, as it encouraged the participants in their own efforts, making them see the project targets as both realistic and achievable.

The programme was also fortunate in that the tobacco control programme manager for HealthBridge Vietnam at the time had several years of experience working in a government hospital. Her experience helped to answer several questions about solving the problems and


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overcoming the barriers while working on the project, which further helped in creating confidence in the success of the project.

3.5.4 Other countries: Expanding S2S HealthBridge’s Programme Director in India provided capacity building and technical assistance to representatives of the South East Asia Region (SEAR) governments participating in the FCTC First Conference of Parties (COP‐1), as well as to governments and NGOs in Indonesia, the Maldives, Myanmar, Malaysia, Democratic People’s Republic of Korea, Bhutan, and Timor Leste. She also worked closely with the South East Asia Tobacco Control Alliance, providing expertise and capacity building at a number of regional or national workshops.

3.6 Component E: Networking Tobacco control organizations tend to be based in the capital or other large cities. These centrally‐based organizations generally have difficulties extending their programmes throughout the country without forming partnerships with other local NGOs based in other areas. For any activity, be it promotion of law, building of public support for policy, or implementation of law, large portions of the country may be neglected if strong national networks do not exist to support decentralization of the work. One key aspect of the S2S programme was the creation and maintenance of such networks (Activity Group 2).

3.6.1 Bangladesh: Building a network from the ground up When WBB began working on tobacco control, it quickly realized that it would be impossible to reach any major achievements if it worked alone. As a result, it was keen to establish a strong network. Even before the legal founding of WBB, its key leaders began meeting with other NGOs working on tobacco control. Within less than a year of establishing WBB, the Bangladesh Anti‐Tobacco Alliance (BATA) was founded, with WBB serving as Secretariat. BATA members were critical for all advocacy campaigns and other activities, including working for law passage and implementation, and for signing and ratifying of the FCTC. The existence of a national alliance greatly increased WBB’s perceived importance in the eyes of government, whereas an NGO acting alone would have had more difficulty getting the attention of important officials.

WBB understood its coordination activities as going beyond ensuring communication and

Impressions: “I and my organization benefited in many ways from participating in a number of workshops organized by WBB. I learned about tobacco control law, gained information about national and international activities, and developed a relationship with government and non‐government organizations, with whom to collaborate on law enforcement. My NGO gained new status. I developed working friendships with a large number of people, and strengthened relationships with many NGOs, my NGO became known to many people, and the capacity of the NGO increased.” ‐‐ Rafiqul Islam Milon, President, Manobik

ʺThanks to RECPHEC for encouraging national and district level NGOs and also providing forum for capacity building of NGOs working on Tobacco Control in Nepal, we are together with Mr. Mulmi in this movementʺ‐ Dr. Mrigendra Raj Pandey, President, National Front Against Tobacco


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collaboration among BATA members and government. It also took an active role in building the capacity of BATA members to work effectively on advocacy issues. Beyond BATA members, it also created a network of hundreds of interested NGOs throughout the country, with whom it maintained regular communication, and whom it guided in advocacy activities. WBB coordinated activities of local NGOs and conducted follow‐up, to ensure a coordinated national programme. Networking activities included:

• Raising public awareness of the need for tobacco control, by assisting and coordinating activities of network members;

• Working with local NGOs to organize demonstrations on policy measures; • Coordinating letter campaigns to thank local and national government officials for

positive actions taken on tobacco control; • Organizing skill‐building workshops at the divisional and national levels; and • Ensuring celebration of World No Tobacco Day at the local and national levels,

including seminars and colorful rallies.

3.6.2 Linking with other NGOs in Nepal In Nepal, as in most S2S partner countries, networks operate at different levels, encompassing NGOs in other countries, those based in the capital city, and those scattered throughout the country. Nepal’s Tobacco Control Network has been active in advocacy and campaigning against tobacco use since 2002. The members represent a wide range of organizations and interests, including medical/health groups, consumers groups, journalists, and child worker advocates. The Resource Centre for Primary Health Care (RECPHEC) was a key member of this network. The network initiated various programmes, and the success of many of those programmes resulted in substantial changes at the planning and policy levels.

Following on its initial policy successes, on 1st October 2003, the network prepared and submitted a draft Tobacco Control Act to the Ministry of Health. It also submitted a memorandum to the Prime Minister demanding immediate ratification of the WHO’s Framework Convention on Tobacco Control (FCTC).

Mr. Shanta Lall Mulmi, President of RECPHEC, coordinated the Tobacco Control Network between 2002 and 2006. After almost four years, RECPHEC felt the need to increase involvement of other members in the network and to develop it as a much broader alliance with periodic changes in leadership to develop common ownership of the network. Then on 31st March 2006, representatives of 13 leading organizations met in RECPHEC’s office and decided to form the National Pressure Group against Tobacco, Nepal. RECPHEC agreed to act as Group Secretariat for two years.

One of the tasks of the Group was to identify what it would do after the Government of Nepal ratified the FCTC. The group decided to translate the text of the treaty into Nepali so that rural people would be able to understand the FCTC, and also decided to begin work on the passage of anti‐tobacco legislation. The Group also regularly updates and disseminates information on


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international initiatives with regards to the FCTC, regularly passing on that information to both national‐level advocacy organizations and district‐level network committees.

Meanwhile, the tobacco control movement in Nepal achieved a significant victory when, on 14 June 2006, in response to a case filed by a network member, the Supreme Court issued a strong judgment against public smoking and tobacco advertising. The Supreme Court asked the government to impose a ban on smoking in all public places, initiate action to ban tobacco advertisement in the print media, raise public awareness against tobacco through the mass media, and to enact necessary and comprehensive anti‐tobacco legislation.

3.6.3 Nepal: Networking at the district level In view of the very unstable political system in Nepal during the course of S2S implementation, and considering that the FCTC ratification process was delayed due to the absence of a proper government, RECPHEC decided to build support at the community and district levels by organizing a series of interactive programmes on the FCTC. The purpose of these programmes was to sensitize community‐based NGOs about the FCTC and Smoking Prohibition Act‐2057. Participants included NGOs, medical teachers, doctors, nurses, and activists, including those campaigning for women’s rights. A workshop in Pokhara led to the decision by the participating organizations to work collectively as a District Level Tobacco Control Network.

In part due to that success, RECPHEC decided to form district network groups. Strong and effective advocacy groups at the district level helped to maintain public pressure at the grassroots level; the districts also contributed to national campaigns. Thus, RECPHEC established networks in 13 districts for advocacy work on the FCTC. A total of 365 NGOs (184 member NGOs and 181 affiliated NGOs) in 13 districts joined in this anti‐tobacco movement.

In view of the overwhelming response and the quantity of awareness and advocacy campaigns organized by the NGO network members utilizing their own resources, RECPHEC decided in 2006 to extend their activities to 12 additional districts of Nepal. Activities carried out at the district level included integrating tobacco control issues into other activities at the community level such as non‐formal education; advocating the local government to take policy measures; encouraging GOs, NGOs, and individuals to create and maintain tobacco‐free zones; distributing posters, pamphlets, and stickers; mounting anti‐tobacco signboards; conducting signature campaigns, and submitting a memorandum to the Chief District Officer for the ratification of the FCTC.

3.6.4 Vietnam: Active collaboration among GOs, NGOs, and international agencies HealthBridge and the World Health Organization in Vietnam jointly established the Tobacco Control Working Group (TCWG) to ensure ongoing communication about and collaboration on tobacco control issues. The network includes over twenty organizations including UN agencies, NGOs and government organizations working in tobacco control. The network members work together to exchange information and discuss issues and solutions in tobacco control. What is particularly important and different about the Vietnam experience is that the network has been successful in including both government and international agencies in close and direct collaboration with NGOs, while in most countries, such working groups, alliances, or coalitions are generally limited to NGOs and possibly media representatives. The success of the initiative


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is in part due to HealthBridge’s many years’ experience of close collaboration across different sectors in Vietnam; with long‐established working relationships, it was possible to formalize the relationships into a working group, which in turn greatly enhances the effectiveness of the work and potential for collaboration of all the partners involved.

3.6.5 India: Coalition‐building across time and space National coalitions are easier to build and maintain in relatively small countries and in those where most political activity takes place in one city (usually the capital). India, on the other hand, has faced tremendous challenges in figuring out how to maintain an active national tobacco control coalition that brings most members physically together.

India also faced additional challenges, in that many groups had a long history of involvement in tobacco control, and thus felt that they were uniquely positioned to offer guidance and leadership within a coalition. Given the size and complexity of the country, a two‐pronged membership recruitment strategy has been important for the Indian coalition. At the national level, members were recruited through national conferences and annual meetings. At the local level, coalition members identified states with little tobacco control, then built capacity of potential NGOs to bring them into the mainstream of the coalition and of tobacco control work.

To facilitate collaborative networking, HealthBridge undertook a number of strategies:

Identifying a workable and common macro‐level goal: national law; Arranging media interviews, and press conferences, so that members could both share their knowledge and gain desired recognition;

Creating “Swiss Cheese” press releases, which included basic information while allowing different organizations to fill in the holes with their organizational name and other desired information; while written by one person (the HealthBridge Programme Director in India), the organization filling in the holes received the publicity;

Co‐organizing workshops, often involving a good deal of groundwork by the HealthBridge Programme Director while giving most recognition to the other organizing agency; and

Co‐organizing activities which involved many responsibilities that could be divided among different participants, such as national conferences.

3.6.6 Philippines: Building commitment and public support within civil society Prior to the S2S programme, a wide section of civil society organizations representing different segments of Philippine society (including farmers, fisher folk, women, human rights advocates, environmentalists, etc.) viewed tobacco control purely as a health matter. HealthBridge supported BILMAKO to work with the People’s Legislative Advocacy Network (PLAN), an umbrella group for more than twenty civil society organizations, to raise awareness of the fact that tobacco control included environmental, social, and economic issues. Following its information raising activities, PLAN’s members unanimously voted to make FCTC ratification and implementation one of its priority legislative agendas for the following three years. BILMAKO’s networking efforts led to the establishment of CHAT – the Coalition for Healthy Alternative to Tobacco ‐ whose initial members come from the consumer movement and the Catholic Church.


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3.6.7 International networking The S2S programme provided support to the World Social Forum (WSF), an open meeting place where groups and movements of civil society meet to debate ideas democratically, formulate proposals, share their experiences freely and network for effective action. Although most of the issues and themes debated in the WSF are interrelated with tobacco control issues, tobacco control is still not a visible part of the agenda of the Forum. HealthBridge also provided support to the Framework Convention Alliance to organize and host international Anglophone and Francophone workshops on the FCTC, in particular to support the participation of key African tobacco control advocates at the FCA workshops in Uganda and Morocco.

HealthBridge’s work was greatly advanced through international networks. Tobacco companies tend to carry out the same activities around the world, be they so‐called youth smoking prevention campaigns, “social responsibility” reports, or lobbying campaigns to avoid passage of strong tobacco control laws or raising of tobacco taxes. When advocates in one country explained how they addressed such issues in their country, that information was often immediately useful to advocates facing the same problem in other countries. International networking allows for greater sharing of information and ideas, and international networks provide support and motivation to isolated activists lacking domestic support.

The South to South network itself was established not only to assist individual countries in their tobacco control policy efforts, but also to increase sharing across countries and regions. Although the S2S partners participating in the frequent e‐mail discussions of the Framework Convention Alliance (FCA) were able to learn about the experiences and lessons learned of their international colleagues; unfortunately, with the development of the FCTC, much of the active discussion on the FCA listserv ceased, and advocates had to turn to their own individual networks for the reinforcement and support they had previously found from the FCA. All members of the South to South (S2S) network expressed that the existence of a network was valuable to them, far beyond simply receiving funding for an in‐country programme, and that they would prefer to remain part of a network than simply receiving independent funding.

3.7 Component F: Public Education While international experience has made clear that public education alone is of little or no use in reducing rates of tobacco use, it can be an important component of a larger tobacco control programme which is mostly focused on law, taxation, and policy. Public education can be vital

Impressions: “WBB has a good relationship with government, and coordinates GO‐NGO activities. As a result, government gives priority to WBB, and regards WBB as the key NGO on tobacco control. A country‐wide network has resulted. With very little time, they can organize an activity wherever they wish. They have trained volunteers who help with other programmes as well as tobacco control.” ‐‐ Enait Hossain, Executive Director, SCOPE (Barisal)

ʺI heartily congratulate Mr. Mulmi [of RECPHEC] for bringing such a large numbers of NGOs for the common issue of tobacco in Nepal. We all are with him in this campaignʺ ‐ Dr. Ms Sudha Sharma, Chairperson, Nepal Medical Association.


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to gaining support for the passage of law and policy, the raising of taxes, and compliance with laws. Most of the partners in the South to South network engaged in public education largely indirectly, through the use of media. While media is an invaluable tool for reaching policymakers, it is also the most cost‐effective way to reach large audiences. For this reason, all of the S2S partners used the media to inform the public about the need for and importance of tobacco control policies. In addition to media work, the partners utilized many other methods to gain public attention and raise public awareness of tobacco control issues. A key theme of the programme has been that tobacco control should not just happen once a year, on WHO’s World No Tobacco Day (31 May). The colorful rallies and campaigns that occur on that day needed to be repeated throughout the year, and S2S partners did so, often through supporting other NGOs to carry out creative activities to attract public attention (Activity Group 3).

3.7.1 Awareness raising and advocacy in Nepal: Reaching the masses At the field level, at Udayapur, Saptari and Gorkha, RECPHEC educated and gave information on tobacco to women receiving Non‐Formal Education (NFE), to different womenʹs groups, Traditional Birth Attendants (TBAs), local youth, community people and GOs and NGOs. For example, those attending non‐formal education received information on different health issues including tobacco. RECPHEC felt that this type of education was very effective because women in turn educate or give information to family members and the community. The coverage from this type of educational programme was significant; RECPHECʹs field programme covered more then 60,000 people, particularly very low‐income groups and marginalized sections of the society. RECPHEC has published information brochures, books, leaflets, quit cards, posters, stickers, and booklets on tobacco, and distributed those materials to network groups.

3.7.2 Vietnam: Reducing the public acceptance of smoking The Vietnam government has faced extreme difficulty addressing the problem of secondhand smoke, due to a very high public acceptance of smoking. Simply banning smoking in various areas would be of little or no use until public acceptance of smoking was addressed, unless enormous efforts in enforcement were possible. In order to support the Government of Vietnam in reaching their goal of reducing the social acceptability of smoking, HealthBridge undertook a project on “reducing social acceptability of smoking” which complemented and contributed to its S2S project. This project involves a partnership between HealthBridge and the Vietnam Public Health Association (VPHA), and collaboration with Vietnam TV to develop seven TV spots to educate the public about the harmful effects of smoking and passive smoking, to encourage smokers and non‐smokers to change their behavior (that is, not smoke in the vicinity of others and to speak out against public smoking), and to promote smoke‐free public places such as hospitals. The TV spots were then aired on two national channels, VTV1 and VTV3, during prime time. The team also worked with Voice of Vietnam (VOV) to develop radio spots, a “Q & A” series, and several other attractive radio programmes. While radio is often neglected


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in media programmes, it can be both an effective and low‐cost way to reach a large portion of the population.

In order to develop the messages and to evaluate their effectiveness, HealthBridge and VPHA conducted a baseline survey together with a qualitative study. The research gathered information for message development and identification of appropriate channels for message dissemination. Both an international and a national expert in health communication were invited to work with the team to design the research and develop the messages. A small study was also conducted to test the appropriateness of TV spots in the community before airing. A post‐intervention survey will be conducted to evaluate the effectiveness of the intervention.

HealthBridge also developed a TV spot to promote smoke‐free public places, focused on hospitals. Other public outreach was done through newspapers, posters, leaflets, and booklets.

3.7.3 Public engagement video HealthBridge took advantage of the presence in the WBB office of an IT intern, Devin James, to create a video about the S2S program. The video explains the reasons for working on tobacco control, and the main components of the program. The video was widely distributed by partners and to the Canadian public.

3.8 Component G: Project Management Successful management of the S2S programme included a close working relationship between the Ottawa‐ and Dhaka‐based HealthBridge teams, its offices in Vietnam and India, and local partner organizations in Bangladesh, Nepal, Niger, and Nigeria. The HealthBridge team completed several activities related to improving the local management of the programme, including conducting administrative audits of some programme offices, providing training in budgeting and forecasting, and technical assistance in financial management and reporting. An internal evaluation of the programme was undertaken towards the end.

3.8.1 Management Structure The S2S project was managed cooperatively at two levels. The HealthBridge team in Ottawa was responsible for overall quality control and management of the project, particularly in planning, coordinating, monitoring and evaluating, and implementation of the project’s activities. This was strengthened by the presence of HealthBridge staff in the field (Bangladesh, Vietnam and India). At the second level, the S2S partners managed their own programmes and reported to Ottawa regularly (see Section 8 below).

In Ottawa, the S2S project was overseen by the HealthBridge Executive Director (Sian FitzGerald). The project activities were co‐managed by a part‐time Project Director (Lori Jones) who had responsibility for narrative and financial reporting as well as some partner capacity building, and by a Regional Director based in Dhaka (Debra Efroymson), who had responsibility for conceptual development and providing technical assistance to the local

Impressions: “The video about South‐to‐South shows so well all the great things that we can do. We never knew that this work was possible.” – Anonymous comment


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partners. A Programme Manager in India, Shoba John, both supported the India program and provided technical assistance to other S2S countries and to international tobacco control efforts, especially as related to the FCTC and in Indonesia. In Vietnam, the Country Director and Deputy Country Director provided technical and management assistance to the Vietnam program (supported initially by a coordinator based in Hanoi).

3.8.2 Interns Devin James served as a NetCorps intern in the Vietnam office, assisting with information and technology issues related to the S2S program, and then went to the WBB office as an intern, where he provided the staff with information/technology training and created the S2S video. In addition, Chinh Nguyen, Andrew Liu, Joe Gamble, and Brian Johnston all served as information technology interns in either HealthBridge’s Vietnam office or at WBB during the S2S programme.

Figure 3: Project Management Structure

CPB/CIDA

HealthBridge HealthBridge

Ottawa HealthBridge

Dhaka

Reporting Relationship Working Relationship

Local Project Partners

Capacity Building

Impressions: ʺThe help we received from HealthBridge in Ottawa for the financial and administrativemanagement of the project meant that we could concentrate on the tobacco control work, like collaborating with journalists, meeting policymakers, and building capacity of local NGOs. There was little hassle over the administrative part, and we always knew we could count on the HealthBridge staff in Ottawa to help us with any difficulty. The technical assistance from HealthBridge staff in Dhaka and Mumbai was also really important for our success.ʺ ‐ Syed Mahbubul Alam, Program Manager, WBB Trust


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4 Results: Goal Achievement The successful completion of the many activities in the S2S Project’s six components fed into the achievement of its three primary outcomes, and ultimately of its overall goal. This section will detail the contribution of the project’s activities to the achievement of its planned results (see Figure 4).

Figure 4: Overview of S2S Project Objectives and Planned Outcomes

The details below refer to the CPB Project Planning Sheet, which is found in Appendix 1. In addition, Table 5 below provides a summary of Output and Outcome Indicators.

Strengthen key tobacco control policies in six countries

Strengthen South-to-South collaboration and networking

Build public knowledge and support for tobacco control policies

Enhanced Government and NGO capacity to develop and advocate for strong tobacco control policies and laws, and enhanced project partner

capacity to provide technical consultation to agencies within each

country and to other partners.

Increased number of NGOs and government agencies engaged in

tobacco control in each country, and improved capacity to effectively communicate tobacco control

information through strong national and international networks.

Increased public knowledge and support for tobacco control policies

and programmes and increased involvement of civil society in tobacco

control efforts.

Component A: Research

Component B: Media Engagement

Component C: Government

Support

Component D: Capacity Building

Component E: Networking

Component F: Public

Education

Direct Activity Link

Indirect Activity Link


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4.1 Assessment of Outcome 1 Tied to Objective 1, Outcome 1 sought “Enhanced Government and NGO capacity to develop and advocate for strong tobacco control policies and laws, and enhanced project partner capacity to provide technical consultation to agencies within each country and to other partners.” This outcome was

achieved primarily through Government Support (Component C) and Capacity Building and HealthBridge Technical Assistance (Component D). In addition, Research (Component A) and Networking (Component E) contributed to the achievement of this outcome.

Tremendous success is evident in each of the six partner countries in enhancing government and NGO capacity to develop and advocate for stronger tobacco control laws. When the S2S Programme began in June 2003, not one of the partner country

governments had signed the FCTC; by the end of the project, all six countries had signed and ratified the Convention. In addition, by the end of the project, national tobacco control laws were in place, or under development, in five of the six countries2. In all of the project countries, HealthBridge’s local partners have earned the respect of government officials (at one level or another), and most are either directly involved in the development and implementation of laws and policies or are called upon for advice. Each has also developed a leadership role in tobacco control within their respective countries. While most of the project partners worked on direct government capacity building and information sharing, some took a different route given local political circumstances. For example, HealthBridge’s local Nepali partner mostly focused on strengthening the capacity of grassroots community organizations given the political uncertainty in that country. When the political situation in Nepal improved, the focus there switched again to include more national‐level advocacy. Most of the project partners have been consulted on tobacco control issues by organizations in other countries, and at the regional level they have been actively engaged in the South Asian Tobacco Control Forum, the South East Asia Tobacco Control Alliance (SEATCA), and lʹObservatoire du tabac de

2 Vietnam is the exception; here there was already a comprehensive policy in place, but the government was not working on tobacco control laws per se.

Table 2: Achieving Outcome 1

Outputs

Trainings, workshops, and seminars conducted

Relevant materials produced and disseminated

Enhanced Government and NGO capacity to develop and advocate for strong tobacco control policies and laws, and enhanced project partner capacity to provide technical consultation to agencies within each country and to other partners

Meetings occurred with policymakers to discuss developing and strengthening tobacco control policies

Country Date FCTC Signed

Date FCTC Ratified

National Tobacco Control Law

Bangladesh 16 June 2003 14 June 2004 Yes

India 10 September 2003 5 February 2004 Yes

Nepal 3 December 2003 7 November 2006 Under development

Niger 28 June 2004 25 August 2005 Yes

Nigeria 28 June 2004 21 October 2005 Under development

Viet Nam 3 September 2003 17 December 2004 No


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lʹAfrique Francophone (OTAF).

4.1.1 Bangladesh In June 2003, the Bangladeshi government was only slightly involved in the FCTC process, there was no tobacco control law in sight, tobacco company advertisements and sponsorships were common and visible, and many NGOs were willing to work on tobacco control issues but did not understand the legal process. The Bangladesh Anti‐Tobacco Alliance had been active since 1999, but had a limited relationship with the government. By December 2006, through a wide range of Government Support and Capacity Building activities (see Section 3 above) WBB was able to change this situation. WBB identified and motivated key government officials about the tobacco control law (why it was needed, what it should include, etc.). It regularly provided information to opinion leaders in government ministries, including HealthBridge and WBB publications. The 1st National Workshop on Tobacco Control, organized by WBB, and ongoing hands‐on capacity building for BATA members continuously built the skills of NGOs throughout the country to participate in tobacco control.

As a result, WBB was able to achieve a number of significant outcomes:

Improved the skills of officials in the Ministry of Health, Health Department, and Ministry of Law, as well as of District Commissioners, Police, and local officials, in carrying out tobacco control activities.

Successfully carried out a number of campaigns to encourage the government to take significant steps towards building strong tobacco control policy, including signing of the FCTC in 2003, ratifying the FCTC in 2004, passing a comprehensive tobacco control law in 2005, and passing the rules to accompany the law in 2006.

Helped the government to write a proposal for, carry out workshops on, and draft a three‐year national plan for tobacco control, under the auspices of the WHO.

Conducted workshops to build capacity of network NGO members in advocacy. Wrote a number of publications to assist advocates in their tobacco control work, and to show to government officials the need to take action on tobacco control policy, and which specific actions to take. Publications covered such issues as the FCTC, implementation of tobacco control law, and the need to raise tobacco taxes.

Produced and disseminated a number of materials, particularly leaflets, stickers, and posters, to raise public awareness on tobacco control issues.

At the same time, WBB was able to considerably strengthen its own capacities to act as a tobacco control leader in Bangladesh. Much of the success of its advocacy campaign was due to its own capacity building on legal issues. Initially, WBB was dependent on lawyers to help it with the issues, which caused substantial delays. WBB therefore sought the help of HealthBridge’s international tobacco control policy advisor, who prepared and sent a draft law, with instructions on how to modify the law according to Bangladesh’s legal system. WBB then assumed direct responsibility for translating the draft law into Bengali, and in the course of doing so, learned much about legal language, as well as the various loopholes in many existing tobacco control laws which were important to avoid.


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4.1.2 India When the S2S programme began in India, the Indian Government’s position on the FCTC was vague. Although national tobacco control legislation had been discussed for more than a decade, little progress had been made. Tobacco advertising remained rampant across all forms of media, the tobacco industry’s promotions were pervasive across sports and cultural events, and smoking in public places was the norm. The Indian Government was unwilling to consider raising tobacco taxes, while the national Tobacco Control movement was limited to only a few active advocates (including HealthBridge). By the end of the programme in December 2006, through a wide range of Government Support and Capacity Building activities, HealthBridge was able to facilitate a number of far‐reaching changes. It provided technical assistance to the State Government of Tamil Nadu in integrating tobacco control into its Health Systems project. It prepared a number of notes and briefs to the national Minister of Health on advertising bans and package warnings, and contributed chapters to key Government of India reports. It also provided direct information sharing and knowledge building with a wide range of government Ministers and bureaucrats. HealthBridge recruited new NGO partners in a number of Indian States, including Gujarat, Madhya Pradesh, Karnataka, Delhi, and Kerala, and provided support to their tobacco control programmes. It helped form the national coalition and provides ongoing support to it.

As a result, HealthBridge was able to achieve a number of significant outcomes:

The Indian Government has come to see tobacco control as a priority area and now initiates policies on its own.

The Presidential task force on tobacco control was created. Significant policy changes have been achieved, including national legislation covering key tobacco control policies:

A ban on direct and indirect tobacco advertising and media promotions with strict enforcement

A ban on smoking in all public places and several indoor workplaces Increased taxes on cigarettes, bidis, and chewing tobacco A ban on tobacco sponsorship of sports within the country. External telecasts, except live, are required to mask tobacco brands

Pictorial warnings have been introduced on tobacco packs The first State‐level tobacco control unit was initiated outside of Delhi. Adapted and produced a number of tobacco control manuals, guides, and fact sheets in Hindi.

India emerged as a leader for South Asian countries, setting a regional example of the sorts of laws and policies that are possible.

In addition, HealthBridge’s Programme Director in India provided technical assistance to the Governments of Timor Leste, Maldives, and the Democratic People’s Republic of Korea in developing national legislation and national tobacco control programmes. As a result, those countries have begun to work on their national tobacco control legislation.

4.1.3 Nepal By the late 1990s, Nepal had one of the highest smoking rates in the world, at 73%. It also had


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the highest female smoking rates, and alarmingly high adolescent and even childhood smoking rates. In an attempt to raise awareness of the harmful effects of tobacco use on human health, the Resource Centre for Primary Health Care (RECPHEC) began to develop advocacy programs against tobacco use in coordination with other NGOs and social activists in 1998. By the beginning of the S2S project, RECPHEC had taken the lead role in coordinating the NGO advocacy group, pressing the government to ratify the FCTC and enact a tobacco control law. It undertook such activities as preparing memoranda to the Prime Minister and Minister of Health on behalf of the NGO anti‐tobacco network, urging them to sign and ratify the FCTC; coordinating a joint government/NGO collaborative meeting to develop a National Anti‐Tobacco Communication Campaign strategy; organizing inter‐ministerial meetings to raise awareness about the FCTC and tobacco control legislation; and hosting a series of other meetings with the Ministry of Heath and Population to inform government officials about the FCTC and the harmful effects of tobacco use.

Although the Government of Nepal appeared to be committed to tobacco control, signing the FCTC in December 2003 with a strong pledge to ratify it quickly, the subsequent conflict situation and dissolution of Parliament and assumption of extra‐constitutional power by the king hindered any further advances. National‐level advocacy work became dangerous and

essentially impossible. RECPHEC’s Chairperson was arrested and jailed, while the activities of its Executive Director were closely watched by the government’s Intelligence Department. However, RECPHEC continued to lead the tobacco control movement, ultimately creating the Tobacco Control National Pressure Group, organizing a global petition campaign to pressure the government to ratify the FCTC, hosting a number of workshops and consultative meetings, and using the media to disseminate

information about tobacco control. With the end of the conflict situation and the re‐establishment of a parliamentary government in 2006, RECPHEC stepped up its efforts to keep tobacco control high on the government’s agenda.

As a result of its efforts, RECPHEC was able to achieve the following outcomes:

Successfully undertook a number of advocacy campaigns that ultimately led to the initiation of the FCTC ratification process; ratification was completed in November 2006.

Mr. Shanta Lall Mulmi, Executive Director of RECPHEC, was invited by the Ministry of Health and Population, the Planning Commission, and the Ministry of Law and Parliamentary Affairs to provide input on draft tobacco control legislation. Amendments were made to the draft law based on Mr. Mulmi’s input and the law is expected to be passed in 2007.

The grounds of Parliament were declared a Tobacco Free Zone. The relationship between advocacy groups such as RECPHEC and the national government have been improved, with the government recognizing the benefits of working more closely with civil society.

RECPHEC has been recognized nationally and globally as the lead tobacco control


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advocacy organization in Nepal. The National Pressure Group on Tobacco was organized and strengthened.

4.1.4 Niger In 2003, international tobacco companies were directly involved in all aspects of Nigerien society, including sports, culture, business, and national institutions, through sponsorships or subsidiary companies. They were thus extremely powerful, had positioned themselves as “benefactors” of the national economy, and supported (or rather controlled) daily life for many people. In fact, political authorities were actually profiting from the sale of tobacco, through the generous financial contributions made to political campaigns by the tobacco companies and their subsidiaries. Therefore, political authorities did not attach any importance to tobacco control or to the harmful health, economic, or environmental effects of tobacco use: with the exception of a single 1992 decree of the Ministry of Trade and Industry (prohibiting tobacco advertising), no tobacco control regulations of any kind existed. In this environment, SOS Tabagisme‐Niger worked to raise the interest of politicians in tobacco control and to develop their capacity to develop, adopt, and implement tobacco control policies. It also sought to build the capacity of NGOs and business associations to get involved in tobacco control.

SOS Tabagisme‐Niger approached this challenge in a number of different ways. It conducted a number of “parliamentary days”, during which information was provided to and discussions held directly with a number of politicians. Meetings were held with the offices of the President and Prime Minister, and with all the candidates of the 2004 presidential election. Periodic meetings were also held with the National Assembly’s Commission on Social Affairs, which was charged with examining the tobacco control law before it was debated in parliament. A number of workshops were organized to raise the awareness of a broad range of civil society actors about tobacco control; participants included opinion leaders, trade unions, NGOs, business associations, and media personnel; and a meeting with managers of restaurants, bars, and hotels to discuss the ban on smoking in public places. Regional and international activities included a regional workshop organized with participants from Burkina Faso and Bénin; an international colloquium with participants from Canada, Burkina Faso, Togo, Niger and the Congo. In addition, SOS Tabagisme‐Niger was involved in judicial activities, by investigating and following up on complaints about tobacco advertising and sponsorships, particularly of youth‐oriented events. By the end of the project, SOS Tabagisme‐Niger had achieved several important outcomes:

Built enough support among national politicians to not only ratify the FCTC, but also to develop and adopt a national tobacco control law to implement the FCTC.

A national tobacco control programme was developed. The social activities of the tobacco companies, including sponsorships of sporting and cultural events, have been curtailed.

Niger, though the work of SOS Tabagisme‐Niger, has become a leader in the Francophone Africa tobacco control movement.


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4.1.5 Nigeria When the S2S programme began, Nigeria already had in place the 1990 Tobacco (Smoking) Control Decree, which had been passed due to the personal commitment of Professor Olikoye Ransom Kuti, the then Health Minister. A bill introducing a comprehensive ban on tobacco advertising, sponsorship and promotion had also been passed by the lower house of the government; however after being sent to the upper house for debate and passage, the bill died. In 2002, the Advertising Practitioner Counsel of Nigeria (APCON) issued a further directive restricting tobacco advertising, including bans on billboards and some restrictions on advertising in the press. However this directive was largely ignored by both advertisers and tobacco companies. British American Tobacco (BAT), the primary tobacco company in Nigeria, had tremendous influence in the country, including over the government, as was widely believed to have ensured the failure of both the bill and the advertising directive.

Environmental Rights Action (ERA), HealthBridge’s local partner in Nigeria, undertook a wide range of activities through the S2S programme to address both the influence of BAT and the weakness of tobacco control policy in the country. It held an ongoing series of House briefings and individualized briefings for Parliamentarians, held meetings with senior civil servants, and provided technical support and background materials to the government about the FCTC and national law development. Particular attention was given to educating policy makers about tobacco issues. ERA was able to establish direct contact with a select number of parliamentarians and government committees under which tobacco issues were being considered. It held an inquiry into BAT’s ‘model farmers’ initiative, proving it to be more harmful than beneficial to the tobacco farmers. ERA also championed the formation of a National Inter‐Ministerial Committee on Tobacco Control. Finally, ERA also worked closely with several state‐level governments to assist them with the development and implementation of local tobacco control initiatives.

As a result of its sustained advocacy efforts, ERA was able to achieve the following outcomes: ERA worked closely with the government to first ensure ratification of the FCTC, and then to prepare for the amendments to the Tobacco Control Act. In doing so, it provided both technical expertise as well as information, and acted as both a partner and an advocate.

An increasing number of policy makers in Nigeria are now championing effective tobacco laws, and have become more passionate and more committed. The leader of the House of Representatives and the Tobacco Control focal person at the Health Ministry have sought ERA inputs on the development of tobacco control strategies.

Nigeria signed the FCTC on June 28 2004, and ratified it on September 29, 2005. The National Inter‐Ministerial Committee on Tobacco Control received presidential approval, and ERA was asked to represent civil society on the committee.

The National Tobacco Control Bill was re‐drafted and presented to the Health Ministry. This bill, once passed, will facilitate the implementation of the FCTC.

Nigeria’s leading tobacco company, the British American Tobacco (BAT), has pulled out all its direct advertising, including branding of restaurants.

4.1.6 Vietnam The first milestones in tobacco control in Vietnam were the issuance of the Government’s


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Resolution No. 12/2000/NQ‐CP on National Tobacco Control Policy for the period 2000‐2010 and the foundation of VINACOSH in 2001. VINACOSH is an inter‐ministerial Committee, comprised of representatives from the Ministries of Health, Education, Finance, Trade, Industry, and the Unions of Trade, Women, Youth, and Farmers, and is responsible for developing, coordinating, and implementing tobacco control policies in Vietnam. The National Tobacco Control Policy addressed all major aspects of tobacco control, including advertising and sponsorship bans, package health warnings, increased tobacco taxes, smoke free policy development and implementation, measures to reduce the smuggling, etc.

Although bans on smoking in most public places, including health facilities, were in place, these bans were poorly implemented and enforced. Smoking rates in the country, and as a result exposure to second‐hand smoke, continued to be exceptionally high. HealthBridge sought to address this situation, particularly as it related to the implementation of smoke‐free hospitals. To do so, it undertook a number of Government Support and Capacity Building activities, including organizing a number of training workshops throughout the country for hospital managers and government officials on smoke‐free legislation and implementation, supporting the Provincial Health Departments to implement smoke‐free hospitals, supporting mass organizations to integrate tobacco control into their programs, and publishing and disseminating IEC materials.

As a result of these activities, HealthBridge achieved a number of key outcomes:

VINACOSH (Vietnam Committee on Smoking and Health) developed a manual on the implementation and enforcement of smoke‐free hospitals.

The Vietnam Government imposed penalties for smoking violations in the medical field. The Government also passed an amendment to the taxation policy, by which tobacco taxes will be increased to 55% in 2006 and 65% in 2008.

Successfully motivated the Department of Therapy to include “smoke‐free” as a criterion in the rating scale used in the annual overall evaluation of hospitals throughout the country. Hospital directors take the evaluation very seriously, as the evaluation indicates the performance of the director and his team. This success ensures the sustainability of the activity, even after the end of the S2S programme, as the Ministry of Health will continue to monitor whether or not hospitals are smoke‐free, and directors will be motivated to comply with government guidelines.

More than 300 health facilities signed a commitment with the Vietnam Health Trade Union to implement a smoke‐free hospital

Six Provincial Health Departments have increased skills and capacity to implement and oversee smoke‐free hospitals, and there is increased support at the provincial level for the implementation of smoke‐free hospitals.

Thousands of health providers have a greater understanding of the dangers of smoking and demonstrate support for and adherence to the smoking bans.

The Women’s Union and Youth Union established No Smoking Clubs, and have greater capacity to provide training on tobacco control to their members.

Increased public awareness about smoke‐free hospitals, through the many informational materials that were designed and distributed in the thousands, including guidelines, “no


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smoking” signs, pamphlets, posters, and stickers.

4.1.7 Other Countries Indonesia is the only Asian country that has not yet signed the FCTC. This has been due, in part, to the tremendous revenue that tobacco generates for the national government (in 2005, tobacco taxes contributed more than 5% of the national budget); the failure to sign the FCTC is also a reflection of the low level of knowledge among Indonesian parliamentarians of the harmful effects of tobacco use and the fact that some existing Indonesian laws actually act as barrier to effective tobacco control. IFPPD sought HealthBridge assistance to build support for a draft tobacco control law by providing opportunities for constructive dialogue and increased media coverage of tobacco control issues. IFPPD had already developed draft tobacco control legislation and was in the process of mobilizing maximum support for its passage from parliamentarians. It had obtained signature support from 222 Members of Parliament, of which 31 were women. An additional 32 female parliamentarians had not yet registered their signature to support the tobacco control draft bill. Although only two additional signatures were added to IFPPD’s motion, and the draft law again failed to be listed in the National Legislation Plan, IFPPD’s interventions resulted in increased understanding of the need to ratify the FCTC and to enact tobacco control legislation among Indonesian women parliamentarians.

In Honduras, support from the S2S programme aided the designation of the Universidad Nacional Autónoma de Honduras (UNAH) as a smoke‐free place. Plans were made to use it as a model to create more smoke‐free areas in other areas of the country.

In part through HealthBridge’s activities, ten of the eleven countries in WHO’s South East Asia region have signed and ratified the FCTC; four have also developed national tobacco control legislation.

In terms of Outcome 1, therefore, through the activities undertaken in Components C and D, in each country both Government and NGO capacity to develop and advocate for strong tobacco control policies and laws has been improved, and HealthBridge’s project partners have enhanced their capacity to act as leaders both within their own countries and regionally.

4.2 Assessment of Outcome 2 Tied to Objective 2, Outcome 2 sought “Increased number of NGOs and government agencies engaged in tobacco control in each country, and improved capacity to effectively communicate tobacco

Impressions: ʺGovernment alone cannot implement the FCTC. For this we need support from Civil Society, NGOs, and the private sector. What Mr. Mulmi is initiating, is in fact contributing to our effort. We highly value his contribution for the last few years in this direction as a leading NGO representative of Nepalʺ ‐ Dr. Nirakar Man Shrestha, Focal Person, Ministry of Health and Population, Nepal


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control information through strong national and international networks.” This outcome was achieved through Networking (Component E). In addition, Government Support (Component C) and Capacity Building and Technical Assistance (Component D) contributed to the achievement of this outcome.

As with Outcome 1, tremendous success was evidenced in each of the six partner countries in building and strengthening national tobacco control networks. When the project began, some of HealthBridge’s partners were working essentially in isolation; by the end of the project, most had established or contributed to the establishment of large country‐wide and in some cases regional, networks. In most of the partner countries there are now many more organizations involved in tobacco control, and the work has spread throughout country at many different levels.

4.2.1 Bangladesh When WBB first started working on tobacco control, many people told its staff that the work was hopeless, and that a tobacco control law would never get passed. However, as noted above, the Government of Bangladesh passed a tobacco control law in 2005 and rules for the law in 2006. These successes demonstrated the strength of WBB’s network activities. Since the

founding of the Bangladesh Anti‐Tobacco Alliance (BATA) in 1999, NGOs have been actively involved in promoting strong tobacco control policies in that country. As Secretariat to the alliance, WBB played a key role in coordinating NGO activities. It conducted workshops to build capacity of network NGO members in networking. WBB’s ability to work effectively at the national level and support the government in law implementation would not have been possible without the

nationwide communication, advocacy, and sharing of materials made possible by its strong and well‐coordinated network. It also created a listserv and actively communicated with the other partners in the S2S network, including through participation in regional and international meetings; and participated in other regional and international meetings, workshops, and conferences, including government and WHO meetings on the FCTC.

Over the 3‐year S2S project period, WBB was able to achieve a number of significant outcomes:

Involved many new NGOs in tobacco control activities, and worked with existing NGOs to keep them actively involved. While WBB continued to play a lead role in advocacy, many of the events leading to the ratification of the FCTC were planned by other organisations, though with support from WBB. Many other NGOs increased their role in, as well as their understanding of, tobacco control issues. By the end of the project, BATA included more


Outputs

Trainings in communication and networking held

Recruitment of new key partners for tobacco control

Increased number of NGOs and government agencies engaged in tobacco control in each country, and improved capacity to effectively communicate tobacco control information through strong national and international networks.

Network and communication systems developed within countries and between the South‐to‐South partners


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than 500 member organisations from all around the country. Attention and priority given to tobacco control and law implementation throughout the country, at the national, district, and local levels, through the active involvement of many new NGOs in tobacco control.

Better sharing of resources; for example, one NGO has resources that are needed by another. Before joining the network, no communication existed; now they are able to share resources efficiently.

Creation of many strong activists at the local level and coordination of local and national‐level activists.

Regular law monitoring throughout the country.

4.2.2 India When the S2S program began in 2003, the national tobacco control movement was limited to only a few active advocates (including HealthBridge). By the end of the programme in December 2006, through a number of networking and capacity building activities, the movement had grown significantly. HealthBridge recruited new NGO partners in a number of Indian States, including Gujarat, Madhya Pradesh, Karnataka, Delhi, and Kerala, and provided support to their tobacco control programmes. It also helped form the national coalition and provides ongoing support to it. In addition, HealthBridge’s staff in India provided technical assistance to tobacco control advocates throughout South and South East Asia. As a result of these activities,

A national coalition of influence vis à vis the Government has been formed and sustained, and is a politically recognized pressure group.

A number of local tobacco control initiatives are now in place, and more NGOs are involved in monitoring law enforcement.

Tobacco control activists have increased capacity and skills in policy advocacy. There is increased NGO activity on FCTC and national law development in Sri Lanka and Indonesia.

A growing number of tobacco control advocates from throughout South and South East Asia have increased their capacity to develop strategic action plans, to monitor the implementation of the FCTC in their own countries, and to develop and implement advocacy activities.

4.2.3 Nepal Prior to the commencement of the S2S project, an informal national tobacco control network already existed. RECPHEC acted as convener of this movement, which included Nepal Cancer Relief Society, Nepal Heart Foundation, Child Workers in Nepal, Mrigendra Memorial Trust, Pro‐Public and Consumer Forum. This informal network was formalized in 2006, as the National Pressure Group on Tobacco. RECPHEC acted as its first convener, and led the growth in its numbers.

Given the severe restrictions placed on national advocacy activities during the period of conflict


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in the country, RECPHEC shifted its focus to the district level. It first organized a series of workshops in Chitwan, Sunsari, Dhanusa, Udayapur and Mahottari in 2003 with the aim of forming a district‐level tobacco control network to create awareness of tobacco control issues, develop NGO solidarity at the district level, and undertake joint activities to advocate to local governments. The primary activities undertaken through the district network included awareness raising campaigns, thematic workshops, advocacy for tobacco‐free public places, and material production (including inclusion of tobacco control in non‐formal education textbooks, CDs, street theatre). It is worth noting that RECPHEC only provided IEC materials and small financial contributions for the district‐level workshops; all other activities were successfully completed with local resources.

RECPHEC also sought and maintained partnerships with organizations at the regional level, including South‐South Solidarity, an Indian‐based organization that focuses on creating strong networks between the South Asian Countries; Voluntary Health Association of India, one of the largest health NGO networks in India; Asian Community Health Action Network, which focuses on community health in India; ARROW, a Malaysia‐based Asian‐Pacific Womenʹs health resource center, and the Peopleʹs Health Assembly Secretariat.

Through its networking activities, RECPHEC realized the following outcomes:

After coordinating the national tobacco control network for more than 4 years, RECPHEC organized a quarterly rotating convenership, thereby creating greater ownership of the network among its members.

The district network which was started with 4 districts in 2003 has now grown to include 30 districts covering more than 60% of the total population.

RECPHEC now coordinates a network of more than 380 NGOs throughout Nepal working on the Health Rights and Tobacco Control Campaign.

Office areas and public place are now tobacco free zones in all 13 network districts.

4.2.4 Niger Given the political and economic power of the tobacco industry in Niger prior to the S2S programme, there were few organizations involved in tobacco control. Those that were

involved, such as SOS Tabagisme‐Niger, faced not only severe financial and logistical difficulties because of the lack of support given to tobacco control, but also death threats. No seminars, workshops, or other demonstrations had taken place to share information and raise awareness about tobacco control. One of SOS Tabagisme‐Niger’s primary objectives was therefore to create a broad alliance of organizations

committed to tobacco control. This alliance would be comprised not just of NGOs, but also of government interdepartmental committees, trade unions, business associations, health care professionals, etc. To create this alliance, SOS Tabagisme‐Niger focused its efforts on widespread communications activities: the publication and distribution of news bulletins and posters; letter writing campaigns and press releases; organization of round tables, conferences, and debates; production of radio spots; and the sponsorship of albums or songs that portray the


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harmful effects of tobacco. Doctors and nurses were trained on nicotine weaning, to build their capacity to act as cessation counselors and workers. Through these activities, SOS Tabagisme‐Niger was able to achieve a number of significant outcomes:

A regional alliance of NGOs and other organizations committed to tobacco control was developed, with organizations from Burkina Faso, Bénin, and Togo.

Business associations and health care professionals are more involved in national tobacco control activities.

A national tobacco control programme has been adopted.

4.2.5 Nigeria In 2003, Environmental Rights Action (ERA) was the primary organization engaged in tobacco control in Nigeria. Through the S2S programme, it sought to build an NGO coalition to coordinate joint initiatives and to increase the number and scope of agencies including tobacco control in their work. ERA also worked closely with youth groups to build their capacity to get involved in tobacco control. ERA led NGO discussions with WHO to get it more involved in local NGO activities. It organized advocacy training for NGOs throughout the country to increase knowledge about tobacco control issues and advocacy skills. It also organized a focus group discussion and skill share session for visiting tobacco control advocates from Ghana, Togo, and Uganda to share their experiences with local tobacco control groups

As a result of ERA’s activities:

The Nigerian Tobacco Control Alliance (NTCA) was formed. The inaugural meeting of the alliance was attended by eight organizations; by 2006, there were more than thirty active members. The NTCA is currently being officially registered as an NGO.

Previously dormant public health NGOs are becoming more active in tobacco control. ERA has established a solid reputation as a leader in tobacco control in Nigeria: most NGOs working on tobacco control continue to seek support or guidance from ERA in designing and implementing their programmes.

4.2.6 Vietnam

As noted above, HealthBridge is the only NGO in Vietnam that has a tobacco control and prevention programmatic focus. Central to its mission is responsiveness to the training and technical needs of local non‐governmental organizations and community coalitions. Shortly

after the S2S programme began, a tobacco control working group (TCWG) was formed, bringing together government organizations, NGOs, and mass organizations that had been active in tobacco control, to provide a forum for the sharing of lessons learned and to discuss emerging issues and solutions. HealthBridge has played a leadership role in the TCWG, which

now has more than 60 members representing more than 20 organizations.

Through the S2S programme, HealthBridge built the capacity of the Health Trade Union of Vietnam (HTU) to participate in tobacco control activities. It provided training‐of‐trainers on monitoring and following up on smoke‐free hospital implementation; initial training


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workshops held with the participating hospitals was led by HealthBridge, while subsequent training was undertaken entirely by HTU.

HealthBridge also began working closely with the Vietnamese Public Health Association, and its affiliate Provincial Health Associations, to increase their capacities to develop and implement tobacco control programmes, including smoke‐free hospitals.

4.2.7 Other Countries In Brazil, the Tobacco Zero Network (RTZ) gained significant credibility over the period that the S2S programme was implemented. In 2003, it was still a virtual network and not well known; by the end of 2006, it had gained credibility and evolved into a registered NGO named Aliança de Controle do Tabagismo (ACTbr). It was regularly contacted as a tobacco control reference point by the media, the general public and other civil society organizations. It established contact with decision makers for advocacy purposes, and engaged the National Consumers Rights organization, with which it developed a civil society platform for Corporate Social Responsibility. This platform gives ACTbr a stronger voice against tobacco industry marketing. Through its work, ACTbr also managed to prevent Brazilian BAT (Souza Cruz) from participating in a panel about risk reduction in an important medical Congress and to reverse a contract made between a reference academic institution and Souza Cruz.

In Honduras, the S2S programme enabled the establishment of the NGO “Alianza Hondureña para la Prevención y Control del Tabaquismo” (AHPRECTA) (Honduran Alliance for the Prevention and Control of Tobacco). The Executive Director of that NGO plays a key role regionally in supporting FCA activities throughout Latin America.

In the Philippines, the S2S programme facilitated the inclusion of tobacco control into the legislative agenda of the People’s Legislative Network (PLAN), by supporting the Bilin ng Mamamayang Konsyumer (BILMAKO) to increase knowledge about the wide range of tobacco control issues among PLAN’s member organizations.

In Indonesia, fourteen NGOs have expanded their mandates to work on tobacco control issues, through the capacity building and networking activities of the S2S programme.

Impressions: ʺWe are working together with RECPHEC against tobacco use. We have more than 280 NGOs working [together in this movement]. We are very encouraged that the Government of Nepal ratified FCTC. This is an outcome of our solidarity.ʺ‐ Mr. Mukti Ram Pokhrel Convener, Health Rights and Tobacco Control Networks, Rupendehi District, Nepal

“The S2S network is very efficient; I have never seen this before. We are doing what everyone else is only talking about” – Inoussa Saouna, President, SOS‐Tabagisme, Niger

“S2S has brought lots of stability to our work” – Akinbode Oluwafemi, ERA, Nigeria


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In terms of Outcome 2 therefore, through the activities undertaken in Component E, in each country tobacco control networks were developed or strengthened. In addition, the value of the S2S network itself was assessed. Much discussion was held over the past year among all partners, centered on the role and value of the S2S network, and whether or not efforts should be made to sustain it. All partners expressed great satisfaction with having been part of the S2S network, and identified its values as:

Solidarity Sharing & learning Contribution to the international body of knowledge Capacity building Partnership with an international NGO Motivation Improved status & credibility Building pockets of expertise Helping each other

The general consensus was that HealthBridge has an excellent international reputation in the area of tobacco control, and that the partners gained credibility by working under its network umbrella. As well, the continuation of the S2S network itself was not seen to be necessarily contingent on the generation of additional funding – as one partner noted “what we have learned we will continue.” The collective impact of the network was seen to far outweigh the individual country‐level successes.

4.3 Assessment of Outcome 3 Tied to Objective 3, Outcome 3 sought “Increased public knowledge and support for tobacco control policies and programmes and increased involvement of civil society in tobacco control efforts.” This outcome was achieved through Research (Component A), Media Engagement (Component B) and Public Education (Component F).

As with Outcomes 1 and 2, tremendous success was evidenced in each of the six partner countries in increasing public knowledge about and support for tobacco control. Several of the local partners have been involved in tobacco‐related research that has generated results to further bolster their tobacco‐control efforts. All of the partners worked on many fronts to improve local understanding of tobacco control issues including media awareness campaigns, material development, and dissemination of research results. In part as a result of their

increased capacity to undertake research through the work undertaken under the auspices of the S2S programme, four of the six S2S partners or their local partners (Bangladesh, India, Nigeria, and Vietnam) received grant funding from the International Union Against Cancer


Outputs

Data on knowledge and attitudes towards tobacco use obtained

Research results published and disseminated

Increased public knowledge and support for tobacco control policies and programmes and increased involvement of civil society in tobacco control efforts. Media networks for tobacco

control organized and managed


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(UICC) to conduct further activities in tobacco control. In addition, four partners of the “extended S2S network” also received grants (Brazil, Honduras, Uruguay, and Pakistan).

4.3.1 Bangladesh When the S2S project began, public awareness of the harms of tobacco use was low in Bangladesh, and journalists were only just beginning to take interest in tobacco control issues. To address these weaknesses, WBB trained NGOs in communications and on working with the media, organized meetings, press conferences, and roundtables with journalists, and conducted research and published many documents on tobacco control, including results of research, and guides on various aspects of tobacco control work.

WBB’s publications on law were extremely valuable in getting the law passed and implementation work underway in Bangladesh, by raising the capacity of local NGOs to work on law passage, and to educate government officials on the importance of law, what law should contain, and why. The publications made clear the importance of banning all forms of advertising and promotion, putting stronger warnings on tobacco packets, and making public places smoke‐free. At various government meetings, its research publications were the only ones available. The publications were also put in government officials’ files and often referred to by them when they needed information on tobacco control. The Minister of Health gained useful information on packet warnings from WBB’s materials, and showed the illustrations in the book at meetings to argue (unsuccessfully, unfortunately) for pictorial warnings.

The publication Tobacco control law: the public demand contained information from surveys on the popularity of tobacco control law. It was, along with the other publications, vital for WBB’s advocacy efforts. Whenever it provided information on different aspects of law, WBB used these publications as resource or reference materials. When both NGO and government officials spoke about tobacco control law in various meetings, they frequently used WBB’s materials as their source of information. This also made it impossible for the tobacco industry to carry their arguments forward, as their arguments were directly contradicted by the abundant data found in WBB’s publications. WBB produced the following3:

• Tobacco control law: why it is needed and what to do • Tobacco control law: the public demand • Tobacco control manual • Hungry for Tobacco • Tobacco and Poverty: Observations from India and Bangladesh • BAT’s Youth Smoking Prevention Campaign: What are its true objectives • Do you know how to quit smoking? (Quit advice) • What is the Framework Convention on Tobacco Control, why is it needed, and what can you do?

3 Although some of these publications were first produced prior to S2S, the S2S funding allowed it to reprint many of its existing publications, and also to disseminate existing ones more widely.


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• Report on the 1st National Workshop on Tobacco Control • Raising the tax on tobacco products: An important solution for increasing government revenue

and public health

As a result of its Research, Media Engagement, and Public Education activities, WBB was able to achieve a number of significant outcomes:

Research results were used to identify areas for stronger implementation. Increased print, radio, and TV coverage of tobacco control issues. Produced publications that proved very useful for advocacy campaigns and as guidance to organizations newly working in tobacco control.

An increase in positive coverage of tobacco control law, the FCTC, tobacco tax, the national three‐year plan, and law implementation.

An increase in media personnel understanding of tobacco control issues. Strong personal relationships with media personnel. A lot of coverage for very little money, including regular coverage of tobacco control on radio and airing of short spots and other programmes on TV.

4.3.2 India In India in 2003, tobacco advertising was rampant across media, and there was little public

awareness of tobacco control issues. However, as noted in Section 3 above, HealthBridge was able to effectively utilize the media to raise awareness of issues such as tobacco industry sponsorship of the Formula 1, and the government ban on smoking in the movies. This ultimately led to a change in the way that media covered tobacco‐sponsored events. In fact, direct tobacco advertising and sponsorship has now disappeared, and the display of tobacco use and brands in films and television serials has significantly declined. A screening committee for violations of the

advertising ban was established with HealthBridge support, and includes substantial civil society representation.

In addition, there is an increased public awareness of the harmful effects of smoking and increased restrictions on smoking in public places.

HealthBridge’s Progamme Director in India also worked closely with the Government of Bhutan to develop a conceptual framework for a qualitative study on the impact of the ban on the sale of tobacco products through out Bhutan.

4.3.3 Nepal By 2000, annual average manufactured cigarette consumption in Nepal had increased more than 300% from 1980 levels. The open border with India had provided ample opportunities to market cigarette and tobacco products in Nepal, even those which were banned in some Indian states. Tobacco advertising and marketing was rampant.

As a result of RECPHEC’s 1998 national consultative meeting on ʺSmoking in Nepal: Present Context,ʺ the chairperson of the Association of Advertising Agencies publicly announced that no tobacco advertisements would be telecasted during the live World Cup, broadcasted


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through Nepal Television. Following this, and with continued pressure from the tobacco control movement, the Nepali government decided to ban the advertisement of tobacco and alcoholic products in all electronic media. However, in spite of this decision, tobacco advertising expanded rapidly, and was found in newspapers, magazines, and on hoarding boards (billboards). Tobacco company sponsorship of sporting events, concerts, and cultural programs also increased significantly. RECPHEC therefore determined that a sustained and long‐term research and media and public awareness raising campaign was necessary.

After meeting with a number of different journalists, RECPHEC assisted a group of ten media representatives committed to tobacco control to form a group called ʺMedia Objectʺ. RECPHEC also worked with HEJAN, a national forum of Health Journalists, which became an active member of the National Pressure Group Against Tobacco. HEJAN contributed to the Tobacco Control Program by developing analytical news stories, TV debates, and feature articles. RECPHEC designed a number of activities to sensitize the media about issues such as tobacco and poverty, tobacco and gender, and tobacco and health. As the convener of the Tobacco Control National Pressure Group, Mr. Shanta Lall Mulmi also participated in a number of TV and radio debates, and oversaw the development of a wide range of public education materials.

RECPHEC undertook its first research study on tobacco in 1998, following which it produced a comprehensive report on tobacco production marketing and use in Nepal. Through the S2S programme, it also collaborated in the conduct of seven additional research studies with a variety of partners, including Media Object and Tribhuvan University.

Through its media and research activities, RECPHEC achieved the following outcomes:

Prior to the S2S project, tobacco was a ʺnon issueʺ for media; however, media personnel now realize that tobacco control is a major media advocacy issue.

Successfully convened and organized two groups of media persons interested in tobacco and health issues: Media Object and HEJAN

Increased positive media coverage of tobacco control issues. The Ministry of Health now awards journalists annually for their contribution to the anti‐tobacco campaign.

The District Network partners developed linkages with local units of the Nepal Journalists Association.

4.3.4 Niger Given, in part, the government’s previous lack of interest in or motivation towards tobacco control, public awareness of the issues related to tobacco use were also low prior to the start of the S2S project. In fact, there was general widespread support for the tobacco industry and its products. Cigarettes were regarded as common foodstuffs, much the same as sugar or flour. There was no media coverage of tobacco control, nor any locally‐relevant research on the subject. SOS Tabagisme‐Niger addressed these gaps by undertaking a major research study on the direct linkages between tobacco and poverty, which enabled it to establish, in a scientific


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way, the contribution of tobacco consumption to the growing poverty among Nigerièns. The study results were disseminated through scientific reviews and conferences. Many tobacco control documents, available only in English, were translated into French for use by media personnel.

As a result of its research and other activities, SOS Tabagisme‐Niger received a WHO award in 2004.

The media in Niger now addresses tobacco control more regularly, and is more interested in the issues related to tobacco control.

The general public is now more aware of the harmful effects of tobacco production and use.

4.3.5 Nigeria The media has a long history in Nigeria of being friendly to the tobacco industry, publishing its press releases while ignoring any opposing viewpoints. As a result, the general public in the country have remained particularly uninformed about the harmful effects of tobacco use. In order to address this issue, ERA undertook a number of media advocacy and research activities.

It hosted a series of workshops and information seminars for journalists, held a regular series of press conferences on a variety of subjects related to tobacco control, and participated in a number of television and radio interviews. It printed and distributed informational materials about tobacco control, and the “antics” of the tobacco industry. ERA undertook regular media monitoring to gauge the type and frequency of reporting on tobacco control. ERA also initiated the creation of

Journalist Action on Tobacco or Health, which focuses on mobilizing youth activism around tobacco control.

Nigeria’s media campaign generated a number of successful outcomes, including:


Success in attracting policy makersʹ attention. Achievement of a partial restriction of tobacco adverting. Direct responses from BAT following a trip organized by ERA for journalists to visit poverty among tobacco farmers, as well as a probe of BAT by the House of Representatives following one of the trips to the farmers and the media campaign around it.

4.3.6 Vietnam Prior to the commencement of the S2S programme, media personnel and organizations did little to address tobacco control issues. One of the suspected reasons for this was that media personnel had low awareness and understanding of tobacco control issues and efforts, and received most of their information on the subject either directly or indirectly from the tobacco industry in Vietnam. To address this situation, HealthBridge project staff members were able to work synergistically among a number of funded projects to hire a media officer, who in turn developed and maintained a media network. The media network meant that HealthBridge


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could develop close relationships with reporters of various important newspapers, who grew increasingly willing to write about tobacco control. In addition, the media officer regularly monitored media coverage for positive and negative coverage of tobacco control and for any evidence of violations of tobacco control law.

In order to promote the concept of smoke‐free hospitals, HealthBridge provided the media with information about the project, including the success and challenges. The media in turn disseminated the project information to the public. Without the use of media, it would not have been possible for HealthBridge to reach such large audiences with information about the importance of smoke‐free hospitals and the need to comply with government regulations making hospitals smoke‐free. HealthBridge provided technical and financial support to provincial health departments to launch World No Tobacco Day public events for all health facilities. It collaborated with local and central television to produce two documentary films, and published articles in various newspapers. In addition, an interview about the project’s activities was produced on Vietnam Radio.

4.3.7 Other Countries In the Philippines, a media awareness campaign supported by the S2S programme resulted in an increase in positive media reporting on tobacco control. HealthBridge’s local partner, BILMAKO, also learned key lessons about media advocacy which will strengthen its efforts in this area. First, that media advocacy in the Philippines against the tobacco industry is particularly difficult during the run up to an election, as this is when the tobacco companies are most active in furthering their business interests and they have influence over every mass communications medium, often through bribery. Second, providing sound scientific evidence on tobacco issues is not sufficient to influence media publications. Rather, there is a need to build a long‐term relationship with media practitioners.

In terms of Outcome 3 therefore, public awareness of and support for tobacco control has increased in all six project countries, as has media coverage of the subject. The media is now more engaged in tobacco control efforts, and is less influenced by the tobacco industry. The research capacity of HealthBridge’s six local partners has increased; the results of their research has been nationally, and in some cases internationally, recognized.

4.4 Assessment of Impact The overall goal of the S2S programme was “To reduce tobacco use and its detrimental consequences on health, poverty, and the environment in six low‐income countries (Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam) by strengthening the countries’ capacity to develop and implement key tobacco control policies (smoking restrictions, warnings for tobacco products, bans on tobacco advertising and promotion, and higher taxes on tobacco products), research, and programs..” While an examination of

Impressions: “Hi Vietnam friends, I think this [international media opportunity] is in part the contributions of your study in Vietnam, right? I remember seeing the smoke measurement kit An had on her bike all the time! Wish you success in using the report with local media” – Shoba John, HealthBridge.


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the achievement of the project’s outcomes would indicate that the project has definitely strengthened capacity to develop and implement key tobacco control policies, research, and programmes, measuring any impact beyond that statement would not be feasible within the timeframe and resources of the project. Significant progress has been made in making tobacco control a priority in each of the six countries which will, in the future, most likely lead to reduced rates of tobacco use and ultimately of tobacco‐related morbidity, mortality, poverty, and environmental consequences. Further, a key lesson of the program for governments is that they can and should take responsibility to curb the activities of companies when such activities are detrimental to public health or the environment. If governments take that lesson to heart and apply it in other areas as well, it would lead to significant, if not measurable, improvements in health and environment.

4.5 Assessment of Variances There were no significant shortfalls between outputs/outcomes planned and achieved. In fact, there were a number of positive variances between outputs/outcomes planned and achieved (i.e., greater successes achieved than originally anticipated), as a result of the evolution of the project’s activities to respond to existing conditions, without losing sight of the original project framework and objectives.

One significant area in which HealthBridge achieved more than it had planned was in the addition of support to several countries not included in the original proposal. The additional activities contributed to strengthening advocacy campaigns in those countries (Brazil, Honduras, Indonesia, Pakistan and the Philippines), and also to increased international lessons learned through sharing with them. For instance, Pakistan’s lessons learned in law enforcement proved extremely useful for WBB’s planning for law enforcement measures in Bangladesh. The collaboration did not stop with the very limited funding that HealthBridge offered; rather, HealthBridge proceeded to enter into closer relationships with both Brazil and Indonesia for ongoing technical support to their tobacco control programs, and is now directly funding a transport policy program with its tobacco control partner in the Philippines, and research on the economic contribution of women through their unpaid work in Pakistan (as well as Nepal and Vietnam; the research has already been conducted in Bangladesh).


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5 Risks and Assumptions

5.1 Assumptions The main assumptions made by HealthBridge when the S2S programme was developed were that, (i) by working together, NGOs would have enough strength to effectively counter the tobacco industry; and (ii) the lessons of Bangladesh were replicable elsewhere (intense inputs of technical assistance and some financial support could make significant changes in the tobacco epidemic). As noted in Sections 3 and 4 above, these assumptions proved to be correct.

An extremely effective programme strategy proved to be enhancing the ability of local tobacco control NGOs to provide support to their governments. The S2S programme was originally designed by a person with a development work background, who strongly believes in relying on local expertise (and strengthening it when necessary), rather than providing ongoing technical assistance and thus creating dependence on outside support. The decision to choose existing strong advocates and provide them mostly with financial and administrative support was based on this philosophy, and paid off in terms of the programme’s remarkable achievements. This approach enabled the S2S partners to both convince their governments to make tobacco control a priority, and lessen the power of the tobacco companies to convince those governments otherwise. At the same time, the previous Bangladeshi experiences proved to be at least adaptable in the five other programme countries: although each political and socio‐economic context was different, the lessons related to capacity building, financial support, and involvement of the media were key to implementing the programme. Perhaps most important was the “working together”: each of the S2S partners gained additional credibility, and therefore local importance, by working as a member of the international S2S network.

Three primary risks were identified and strategies to overcome them identified; they are discussed below.

5.2 Output Level Risks At the Output level, the main risk identified was language barriers among the various S2S partners would hinder effective networking. The S2S partners were mostly non‐native English speakers, and one in particular had extremely limited English. This inhibited direct communication with other members and also limited the sharing of regular reports and lessons learned.

The S2S Programme Team addressed, and mitigated, this risk directly through a number of means. The inclusion of the Niger partner was possible due to the fact that HealthBridge staff included French speakers who could communicate directly with him, and then share his information with the rest of the partners. The Niger partner also used some of his project funds to build his own capacity, by attending a 3 month English‐language course in Canada. It was interesting to note that the language problems nearly disappeared during direct interpersonal encounters; when the Niger partner shared a hotel room with people from other countries, they immediately became close friends, enjoying the challenge of conversing with very limited language. Overall, it seemed the inclusion of a virtual non‐speaker of English, while making communication more difficult and increasing the burden in terms of needing to translate many


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group e‐mails into French, in no way reduced the effectiveness of the work, and the benefit of including a different culture and perspective in the network far outweighed any disadvantage. As to language limitations among the other countries, these were mitigated due to the Regional Director’s fluency in several languages and assistance in drafting English‐language messages, and the availability of the Project Director to edit poorly‐written English‐language reports submitted by the partners.

5.3 Outcome Level Risks At the Outcome level, the main risk identified was that the tobacco industry would have the resources to lobby heavily against policies designed to protect the public from the tobacco epidemic. Africa in particular is one of the targets of the tobacco companies, as are women and youth. The tobacco industry is extremely strong, powerful, well‐organized, and has enormous advertising budgets. Countering this strength with the small amount of funds available through the S2S Programme, and with relatively small NGOs in developing countries, could appear to be a daunting task.

The S2S Programme Team addressed, and mitigated, this potential risk in a number of ways. Tobacco is unique in that much of the problem is generated by a single industry, and that relatively simple actions (e.g., passing and enforcing national legislation) have a tremendous positive public health impact. Therefore, the Programme team focused its efforts on those activities most likely to make a difference: Research, Government Support, Capacity Building, Media Engagement, and Public Education. Taken together, these programme components generated both the public and political support required to counter the efforts of the tobacco industries in the S2S countries. Simply put, right can be stronger than might; that is, working to improve public health and reduce wasted expenditure on tobacco, because it benefits the majority, naturally carries more weight than the deceptions of an industry seeking only to increase its profits. Thus while the industry did lobby heavily, the S2S partners were able to counter the lobbying effectively. The two major tools were information and pressure: sharing information with governments that countered industry arguments, and using media to maintain pressure on governments to “do the right thing”. As mentioned above, the ability of NGOs to successfully motivate governments to act in the public rather than in commercial interests is an excellent example of good governance, and proves that even health programming can further democracy if advocacy is properly managed.

5.4 Impact Level Risks At the Impact level, the main risk identified was the lack of political commitment to tobacco control, or political uncertainty hindering government ability to work in tobacco control in any or all of the six partner countries. Although this was a serious risk, it was also the main impetus for the programme. As noted in Sections 3 and 4 above, a significant proportion of the project activities focused on providing government support, including capacity building, knowledge sharing, and technical assistance, in order to build political commitment to tobacco control. That is, the S2S Programme Team’s primary mitigation strategy to deal with this risk was Component C (Government Support) and Component D (Capacity Building). In addition, the results of Component A (Research) helped to provide the specific information needed by government officials to make tobacco control a priority in some countries. As mentioned elsewhere in this


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report, all partners achieved significant success in increasing government support for tobacco control.

In countries where political commitment was completely lacking, such as in Nepal after the King suspended the government and assumed all authority, the S2S Programme team took a different approach and focused its efforts on the grassroots organizations at the District level, building support and momentum for tobacco control at that level instead of at the national level. Thus, by being flexible, the programme was able to make significant progress at the District level, which then enabled the national level government to move more quickly once the peace process was established and governing authority was returned by the King.


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6 Gender Equality Women are affected by tobacco through various ways: by the health and economic effects of their direct tobacco use; by the health and economic effects of tobacco used by other family members; and by their subjection to inhuman working conditions in various aspects of tobacco cultivation and production. While in Southeast Asia rates of smoking among women are very low, the rates among men are very high, so that women are greatly affected indirectly. In Nepal, rates of smoking among women are the highest in the world.

The S2S Programme complied with CIDAʹs Policy on Gender Equality. In particular, it assisted in strengthening the capacity of partner institutions, governments, and civil society organizations to promote, design, and implement policies, programmes and projects which reflect the needs, priorities and interests of both women and men, and support gender equality. HealthBridge’s partners conducted a number of activities with a gender focus, and positive synergy ensued due to the receipt of a CIDA‐funded program for three of the partner countries (Bangladesh, India, and Vietnam, with HealthBridge direct funding being spent on research in Nepal and Pakistan) directly addressing gender equality. That is, the simultaneous implementation of S2S and a gender programme meant that lessons learned in gender equality were directly transferable to S2S.

Examples of direct gender‐related work among the S2S partners included:

In Bangladesh, WBB reprinted a manual which included information on tobacco and women, and held several classes on gender issues to sensitize its staff members to the connections between gender and tobacco. WBB works actively with the Forum for the Girl Child and other NGOs working on gender issues , and WBB staff attended a regional workshop, and arranged the participation of an official of the Ministry of Law, on gender and tobacco in Taipei (at which HealthBridge’s Regional Director was one of the speakers). It also participates in HealthBridge’s Gender Project, (supported by CIDA), which will further strengthened gender programming in tobacco control.

Tobacco Control was an issue brought by HealthBridge’s local partner (Redeh) to the Women’s State Conference in Bahia Brazil.

In India, a two‐hour workshop was organized for the engineering students of Sikkim Manipal Institute of Technology on identifying and acting on tobacco industry strategies targeting youth. Women constituted 50% of the participants, which would help in empowering the young women against the tactics of tobacco companies. More than 300 women from low‐income groups were mobilised through the awareness programmes of a local partner to participate in a public rally and workshop in Trichur town, highlighting the tobacco‐poverty linkages on World No Tobacco Day.

RECPHEC in Nepal directly addressed gender issues by teaming up with a Womenʹs Studies Program to conduct research. Printed information on tobacco and gender was used to sensitize workshop participants and other networking group about issues related to tobacco and gender.

In Niger, our local partner undertook a study on tobacco use among women in collaboration with l’Association des femmes du Niger. In Nigeria, the tobacco industry targeted women


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with a view to recruiting them as tobacco users. The ERA anti‐tobacco campaign sought to counter the industry’s activities and encourage women to live healthy lifestyles. More women are now aware of the dangers of tobacco consumption, and a number of ERA’s new NGOs partners have women as their leaders.

Among the new partners in Viet Nam are women’s groups and associations. In addition many of the issues focused on had a direct impact on women, for example, efforts to educate men to not smoke around their children. Most IEC materials and training work about non‐smokers focused on the protection of women and children from passive smoking. These activities enabled women to improve their knowledge about the harmful effects tobacco and to protect themselves from it.

In terms of programme management, HealthBridge’s Executive Director, Regional Director in Bangladesh, Programme Director in India, Deputy Country Director in Vietnam, and Director of Special Projects are all women. Many of the project staff in each country were also women.

Thus, while neither explicitly a gender‐focused project nor one that focused on improving the lives of women, the S2S Programme had a very strong gender component.


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7 Public Engagement A key aspect of HealthBridge’s project work in Canada is information dissemination activities and advocacy about international health and development issues, including tobacco control. HealthBridge sees public engagement as a means to provide education and information to the Canadian public and to international audiences, particularly those working directly and indirectly in the health and related sectors, about the key issues and research results generated through its projects and programmes. The goal of HealthBridge’s public engagement is to share experiences and knowledge, to build awareness, and to increase public interest and involvement in the development and implementation of health and development activities that could provide benefit to the populations of developing countries.

HealthBridge used several different venues to disseminate information about the S2S Programme to the Canadian public. A number of guides were developed and/or updated and widely disseminated both through conferences and the website, including various guides translated into Spanish, French, Bengali, and Hindi. Journal articles were published. A multi‐lingual (English, Spanish, French, Vietnamese and Bengali) kit on tobacco and poverty (including a CD presentation to music, a leaflet, a poster, stickers, and postcards) was prepared for use in Canada and partner countries to educate people about the effect on smoking on poverty. Presentations about the programme were made at the 2005 National Conference on Tobacco or Health. In 2005 and 2006 some of the S2S partners made presentations highlighting lessons learned and results achieved at the Canadian Conference on International Health (CCIH), which attracts approximately 500 participants. In both instances, the programme partners also had the opportunity to make linkages with additional Canadian organizations. HealthBridge’s website provides an additional forum for the dissemination of information to the general public. A project‐specific page was developed and maintained, as has been done for HealthBridge’s other projects. A project brochure was developed and distributed during public events. A video documenting the project was also produced and widely disseminated. HealthBridge Programme staff participated in conferences, workshops, and seminars on topics relevant to this project as an opportunity to promote the programme and its results. Finally, HealthBridge’s membership in the Canadian Global Tobacco Control Forum put it in a good position to highlight and disseminate the programme results and lessons learned to the broader Canadian tobacco control community.

At a more personal level, the S2S Programme hosted three young Canadian professional interns, who, while providing significant technical assistance to the project, often had their first experiences with international development. According to their end‐of‐internship reports, each was profoundly affected by his time working on the programme, and had a much greater appreciation for the international development community. One intern, after serving in Vietnam, was invited by WBB Trust to work with them, where he assisted with the production of the S2S video. They each learned about tobacco control and health sector issues, which in many cases was new to them, as well as about local politics.

Internationally, HealthBridge attended a variety of international meetings, workshops, and conferences where it spoke about the programme, including meetings in Egypt, Helsinki, Malaysia, Spain, Taiwan, Thailand, and the United States.


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8 Shared Responsibility and Accountability HealthBridge’s approach to project management emphasizes the active participation of local partners, which supports an integrated approach to capacity building using participatory planning and evaluation practices. A formal partnership agreement between HealthBridge and each of the local partners was developed at the beginning of the programme to detail each partner’s specific roles and responsibilities; how the team would work together, including guidelines and procedures for financial reporting, decision‐making, and logistics. Ultimate accountability, however, rested with HealthBridge, as the Contribution Agreement Signatory.

HealthBridge assumed overall project management and financial responsibility for the S2S Programme, including the provision of Canadian technical assistance, identifying and recruiting interns, project monitoring, control, management of financial risk, and reporting to CIDA. This management also included conducting several project review missions. In addition, HealthBridge was responsible for Canadian public engagement and information dissemination activities. It also provided capacity building in project management to the local partners, through regular correspondence and specific skill‐building workshops.

Each of the local partners was responsible for the design and implementation of its own activities. They also represented the programme to international audiences whenever the opportunity presented itself, providing a local “face” to the programme. Some of the local partners hosted Canadian interns, providing mentoring to them. The local partners worked with HealthBridge to develop semi‐annual work plans and quarterly budgets, and provided monthly narrative reports on activities, outputs, outcomes, and related expenses. These reports were rolled up into HealthBridge’s reports to CIDA.

In terms of the specific activities, HealthBridge was responsible for providing conceptual input, which was then adapted to the local contexts by the partners, with HealthBridge oversight. However, the overall program direction in each country was shaped by the local partner, utilizing its expertise and knowledge of its local conditions and ever‐changing political situation. This combination of support and advice from Canada, with local expertise and independence, was critical for programmatic flexibility that allowed the individual successes unique to each country.


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9 Sustainability HealthBridge sought to increase the capacity of local NGOs and build a strong international network among them to reduce their reliance on technical and ultimately financial assistance from developed countries. The enactment and enforcement of tobacco control laws in each country means that the programme will continue to achieve benefits far into the future.

Ideally, the governments in the six countries would have put into place a funding mechanism for tobacco control and health promotion, based on a portion of the tax for tobacco (and where relevant, alcohol), as has been done successfully in Australia and Thailand4. However, it generally takes at least 10 years of advocacy activities to gain a dedicated tax, so this has not yet occurred. Even if no funds were found to continue the S2S Programme into the next phase, the benefits of the strengthened local institutions, media coverage, and support among NGOs, policymakers, and the general public for tobacco control policies, and international networks, means that tobacco control is likely to continue to be strong in the future.

Fortuitously, just as the S2S program was coming to a close and in fact had entered its no‐cost extension, an announcement came of significant new funding for tobacco control through the Bloomberg Initiative, releasing US$125 million into tobacco control efforts in low‐ and medium‐income countries for two years. HealthBridge helped its partners (including in Indonesia and Brazil) draft letters of intent, and will help draft proposals for those LOI that are accepted. As mentioned above, the experience gained through S2S will be critical to improve the chances of partners to gain funding for their ongoing tobacco control work. HealthBridge Vietnam has also been successful at obtaining financial support from a wide range of donors, thereby increasing the size and impact of its tobacco control program far beyond what would have been possible with CIDA funding alone.

Ownership of the programme, and of the S2S network through participatory approaches in the design, implementation, and evaluation of the programme will also contribute to longer term sustainability. Collaboration and sharing of information, lessons learned, and methodologies with other local organizations, international agencies and other funders further enhances the potential long‐term reach and effect of the programme.

For example, in mid‐January 2007, just following the end of the S2S program, a senior official in the Bangladesh Ministry of Health invited the Executive Director of WBB Trust to serve as special guest at a workshop on tobacco control. The official explained that due to his absence, he was relying on WBB staff to inform the new Joint Secretary about tobacco control developments and needed actions. Following the meeting, the government officials warmly thanked the WBB Executive Director for his presentation, and the Joint Secretary requested WBB’s support in creating more Powerpoint presentations on tobacco control issues. The WBB Executive Director agreed, on the condition that the Joint Secretary would approve a government‐sponsored ad in newspapers, designed by WBB, informing people of the smoke‐free place provisions in the law. Thus the sort of inputs that CIDA funding made possible are continuing beyond the program,

4 Unfortunately, this is not yet done in Canada.


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thanks to the relationships and skills developed during S2S.

On the same day, a colleague from outside of Dhaka informed WBB staff members that local shopkeepers were refusing to post cigarette signboards on their shops, as they knew it was illegal. When the tobacco industry identified the person who was supporting this opposition, that person decided, after discussion with WBB staff, to organize a letter campaign from local shopkeepers to shopkeepers throughout the country, urging them to follow their example in refusing industry pressure to break the law. Once again, relationships and initiatives begun under S2S are continuing beyond the program.

A key lesson learned in sustainability is that, valuable as ongoing funding is, the relationships and skills built under an intensive program will carry benefits far into the future. Of particular note, all of HealthBridge’s local partners in the S2S programme are now closely involved in, and play leadership roles in, the ongoing Conference of the Parties (COP) to the WHO Framework Convention on Tobacco Control. The fact that each is now recognized internationally for his or her expertise and successes in tobacco control is a significant testament to the success, and longer term sustainability, of the S2S network.


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10 Lessons Learned Due to the overwhelming success of this program, and the desire to share some of the keys to that success with international partners, HealthBridge has prepared a public engagement document about the lessons learned through the implementation of the S2S project, entitled “South‐to‐South Collaboration and Capacity Building for International Tobacco Control”. The document is included separately with this report, and a summary of the lessons learned is presented below.

Component A: Research While a large amount of research has been conducted already on tobacco, sometimes key research projects that would prove essential in gaining support of policymakers to tobacco control are lacking. Activists should identify such possibilities of research with specific advocacy goals, and where needed, carry out and widely disseminate the results in order to help achieve their desired results. Publication and distribution of research reports can prove to be critical in gaining new allies and advancing the political agenda for ratification of the FCTC and passage of tobacco control laws. Research reports can also serve to counter claims made by the tobacco industry, such as that the industry is economically important for a country. Published research enables advocates to have in hand the information necessary to make valid arguments. Where appropriate, targeted research designed to respond to a specific argument against tobacco control, or a specific concern, or to highlight the need for action, can be invaluable for advancing the tobacco control programme.

Component B: Media Engagement In order to reach a large audience at little expense, and to raise government and public awareness of an issue, the media are indispensable. Newspapers, radio, and TV are excellent ways to communicate both with a general audience and with policymakers, and media can often be accessed at very low cost. Partners in the S2S network quickly became experts at communicating with and engaging the media, or further enhanced existing expertise, and successfully garnered the needed media attention. Being creative helps to gain positive media attention and makes tobacco control issues more appealing: messages should be sufficiently interesting, and not repeat the same information (for instance, always about health). Journalists and editors often prefer controversial messages or ones addressing issues of politics and economics. By studying media and identifying the best ways to access them, success can be achieved despite the tobacco companies’ large advertising budgets; such success can spread to other fields of work as well.

Component C: Government Support Successful tobacco control work necessitates the establishment of close, positive, mutually‐beneficial working relationships, in which NGOs provide a service to governments and yet maintain the independence with which to criticize governments if they fail to act to protect health. It is not enough to pass a law, if the law is not enforced. Nor is it acceptable to place the entire burden of law enforcement on already over‐burdened governments, which lack the capacity to do so effectively. NGOs can and should play an important role in ensuring that laws are properly enforced throughout the countries in which we work. Mutually‐supportive GO‐NGO relationships can lead to improved policy development and implementation, with NGOs helping to strengthen governments while still retaining the ability to criticize as needed. NGOs should not assume that governments can bear the full responsibility for law enforcement. Where enforcement is lacking, NGOs should assist governments in strengthening enforcement.


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Component D: Capacity‐building and Technical Assistance When done appropriately, capacity building and technical assistance activities are essential tools for ensuring that local partners have the required skills to engage successfully in the types of activities that will likely reduce tobacco use. Skills building can be provided across a number of different areas, including but not limited to media engagement, research, networking, materials development, advocacy and government support. In addition, providing technical assistance in planning, coordination, reporting, and financial management, particularly to a network of partners, can streamline project management and make it much more efficient and effective. Capacity building of key individuals can help ensure that those working on tobacco control engage in efforts likely to be successful in achieving reduced rates of tobacco use.

Component E: Networking Many of the countries participating in the S2S network are too large for the central government, or central NGOs, to effectively oversee activities and law enforcement throughout the country. It is thus often vital to involve local organizations and ensure their active participation in the types of tobacco control activities that have proven to be effective at reducing tobacco use. As an essential aspect of decentralizing the work, NGO leaders must understand how to manage a network effectively, so as to facilitate cooperation. In order to work effectively throughout a country, NGOs should look at building the capacity of smaller NGOs based in locales far from the capital, and at ensuring strong networking among NGOs throughout the country. A key technical skill often neglected in tobacco control and other development work is the management of different personalities in order to achieve successful collaboration. Management of networks involves many skills, which must be learned in order to ensure effective cooperation and a genuinely national programme. Working through global networks, such as the S2S network, provides added value to the work of local NGOs, by exposing them to a wide variety of experiences and expertise that otherwise would not be accessible.

Component F: Public Education While the focus of the S2S programme was on policy, public education was also essential for gaining the momentum needed to ensure passage of policies, and compliance with policies once passed. The public can and should be involved as an active partner in tobacco control work, as long as the focus is kept on the policies that have proven to be effective, rather than on public education without the support of law and taxes. Public education can be an essential component of a comprehensive tobacco control programme, ineffective though it is as a stand‐alone programme. NGOs should work to create public support for tobacco control policies in order to ease the passage and enforcement of laws and policies.

Component G: Project Management There were also a number of lessons learned through the implementation of this project which related, to one degree or another, to how HealthBridge managed the programme. These include:

Managing difficult political situations – Ideally, stable political environments facilitate tobacco control work. However, in many cases, HealthBridge’s partners must work in unstable environments where frequently changing political leaders, political clashes, and even shut‐downs make the work extremely difficult. It is possible to adapt working methods to adjust to the difficulties created by politics, ensuring that the work continues despite external problems. The best‐laid plans can go awry when political problems make planned work


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impossible. A flexible approach can help local partners ride out such difficult periods, laying the groundwork by conducting in‐house work for which they otherwise have little time, or shifting their attention to less political arenas while waiting for the situation to resolve.

Publications for international use – It is wasteful to expect NGOs in each country to “reinvent the wheel” in terms of learning strategies to deal effectively with the obstacles placed by the tobacco industry, reluctant governments, and media which seems in the hands of the tobacco industry. By sharing strategies and successes through the publication documents and can be shared internationally, HealthBridge’s local partners greatly increased the effectiveness of their work. Even though it is a significant amount of work to prepare and disseminate such documents, it is essential for international cooperation, sharing, and progress. Efforts should be made to develop publications that can be used internationally, to share strategies and working methods. This will increase the chances of achieving positive policy change and appropriate implementation. Since many people working in tobacco control are not native speakers of English, such documents should be written in simple, straightforward language, be clear and to the point, and where possible, be translated into other languages.

Importance of on‐going, long‐term, and flexible funding – Tobacco control activists should have the freedom and flexibility to focus on their work and create long‐term plans, rather than always worrying about how to pay next month’s office rent and salaries. While seed grants and other short‐term, small projects can be of great importance, major changes in policy and enforcement will be unlikely to occur without longer‐term, sustained funding that allows activists to carry out sustained advocacy campaigns. Much advocacy work consists of communicating with other NGOs and with government officials, and the main costs involved are thus office space, communications, and salaries. Overhead support for these costs is vital to the effectiveness of the work, and grants to support tobacco control should include and possibly even prioritize such “unglamorous” recurrent costs, as opposed to focusing on specific, short‐term, but possibly less effective projects.

Importance of supporting sustained activities, not just capacity building/workshops – While capacity building is vital, it is not the only element needed to achieve success in tobacco control. Capacity building should complement, rather than supersede, the long‐term, day‐to‐day activities that create policy change. Much expertise already exists in tobacco control, and funding should focus on assisting existing, skilled activists to carry out their daily work, rather than focusing on high‐cost, short‐term workshops which may in the end achieve little, due to the lack of sustained funding for the participants in their home countries.

Importance of supporting highly skilled local activists and NGOs rather than just “fly in the expert” approach – Local expertise should be recognized and acknowledged, rather than always assuming that external experts are needed. As with capacity building, international experts should complement rather than supersede local activists. Useful as the injections of knowledge can be, they need to be injected into existing programmes with sufficient funding to ensure that activists can achieve their goals. Attention should be given to supporting local activists and NGOs, and ensuring that international experts complement rather than supersede in‐country programmes.


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11 Assessment of Environmental Results This project was not required to undertake an environmental assessment.

12 Project Evaluation This project was not evaluated by CIDA.

13 Goods Purchased for the Project The following list identified major goods purchased with project funds. All items purchased remain with the local partners for whom they were purchased. All major purchases were undertaken following CIDA procurement policy.

7 Laptop computers: Vietnam (2), Niger (1), Nigeria (1), Ottawa (3)

1 LCD Projector: Vietnam

2 Digital Cameras: Bangladesh (1), Vietnam (1)

1 Overhead Projector: Bangladesh

1 Scanner: Bangladesh

1 Printer: Vietnam


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14 Performance to Budget

The following pages provide the final financial report, capturing all expenses incurred over the life of the project, as well as the explanation of variances.

14.1 Explanation of Variances


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S2S FINAL REPORT (JUNE 2003 – DECEMBER 2006)

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Appendix A: CPB Planning Sheet

Table 5: CPB Project Planning Sheet

Programme Title: South‐to‐South Collaboration and Capacity Building for International Tobacco Control CPB Partner: HealthBridge CIDA Officer: Anik Brunet Programme‐Project #: S 62163 Start: April 2003 End: March 2006

Priorities: Basic human needs

Branch results: Capacity building in developing countries, support for official development assistance, leverage, and sound project management and administration

Countries: Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam

Total budget: $1,264,110 CIDA contribution: $808,667

Objectives: 1. Strengthen key tobacco control policies in six

countries by building capacity of Southern partners to advocate for these policies and to engage in effective tobacco control measures.

2. Strengthen South‐to‐South collaboration and networking.

3. Build public knowledge and support for tobacco control policies.

Goal: Overall goal: To reduce tobacco use and its detrimental consequences on health, poverty, and the environment in six low‐income countries (Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam) by strengthening the countries’ capacity to develop and implement key tobacco control policies (smoking restrictions, warnings for tobacco products, bans on tobacco advertising and promotion, and higher taxes on tobacco products), research, and programmes.

ACTIVITIES OUTPUTS OUTCOMES IMPACT 1. In collaboration with government staff and NGOs, project partners will: conduct workshops, seminars, and other capacity building activities for government staff and NGOs on the evidence base for key tobacco control policies; train other agencies on how to advocate for the policies; and identify relevant materials to

1. Trainings, workshops, and seminars are conducted; relevant materials are produced and disseminated. Meetings occur with policymakers to discuss developing and strengthening tobacco control policies.

2. Trainings in communication and

networking held; recruitment of

1. Government and NGO staff will know how to develop and advocate for strong tobacco control policies; increased promotion and advocacy for strong tobacco control laws; materials for key policy areas are disseminated to tobacco control stakeholders in each country; project partners have capacity to provide technical

Improved health of women, children and men, reduced poverty among families, and less destruction of the environment, in the target countries.


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produce and disseminate to tobacco control stakeholders. Provide more generalized training to NGOs on tobacco control work including management, evaluation, and fundraising.

2. Training of project partners in networking and communication; identification and recruitment of new key agencies into tobacco control network; establishment of intra and inter‐country communication network via listservs, newsletters, and regional meetings.

3. Conduct surveys to assess public knowledge and attitudes on tobacco use; work through South‐to‐South Network to identify and communicate new and key existing tobacco control research to the media; translate and adapt key HealthBridge documents; produce and distribute key documents to the media and NGOs; conduct relevant research as needed to advocate for tobacco control policies and to increase understanding of the tobacco issue locally; conduct media training; South‐to‐South Network issues bi‐monthly and ad hoc press releases

new key partners for tobacco control; network and communication systems developed within countries and between the South‐to‐South partners.

3. Data on knowledge and attitudes

towards tobacco use obtained; research results published and disseminated; media network for tobacco control organized; media products developed; media training conducted; press releases issued and press conferences held.

consultation to agencies within each country and to other Southern partners.

2. Increased number of NGOs and government agencies engaged in tobacco control in each country; project partners increase tobacco control communication and networking activities; South‐to‐South listserv, newsletter, and other communications established and maintained. Project partners have increased capacity to communicate tobacco control information and have a developed infrastructure for sharing news and information as well as coordinating tobacco control efforts. More Southern NGOs consult other Southern NGOs directly for assistance. More people reached through NGO activities on tobacco control. Strong and active network of Southern NGOs operates.

3. Increased public knowledge and support for tobacco control policies and programmes. Increased involvement of civil society in tobacco control efforts. Public awareness of health risks, economic burden of tobacco use,


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and conducts press conferences. and tobacco control policies increases in each country; credible and accurate media coverage of tobacco issues increases.

PERFORMANCE INDICATORS 1. Number of trainings held and

number of participants attended; post‐training evaluation with participants; number of materials printed and distributed, and reach of materials (how many languages and countries).

2. Number of trainings held; existence of South‐to‐South listserv, newsletter, or other communications; number of organizations and individuals regularly receiving news and information, through established communication networks.

3. Research results obtained and analyzed; publication of research results; number of presentations of research results in public forums; number of media trainings held; number of press conferences held.

1. Number of meetings project partners have with policy makers to advocate for stronger tobacco control policies.

2. Number of request to partners

for technical guidance and consultation; number of new agencies involved in tobacco control; documentation of NGO communication and networking activities.

3. Surveys of public awareness regarding tobacco control hazards conducted; media analysis for coverage of research; number of credible and accurate print and electronic media reports.

1. Number of NGOs that advocate for improved tobacco control laws; number of policy makers who consider stronger tobacco control laws; documentation of changes in policy.

2. Records of national and

regional coordination and consultation for tobacco control; number of tobacco control activities that are coordinated across various agencies.

3. Survey to assess support for tobacco control and tobacco control policies.

REACH 1. Members of NGOs, government staff, and members of the media who gain knowledge, experience, and confidence in tobacco control (with

positive implications for their other work as well). 2. Women, children and men will be less exposed to tobacco smoke from others. 3. Women, men and youth will be less likely to use (smoke or chew) tobacco.


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4. Women and children will eat better and have other basic needs met, as the men spend less on tobacco and more on basic needs. 5. Youth will be less likely to take up smoking. 6. NGOs in developing countries working in tobacco control will have greater access to relevant materials and information. RISKS AND ASSUMPTIONS Assumptions: By working together, NGOs will be powerful enough to effectively counter the tobacco industry; the lessons of Bangladesh are replicable elsewhere (intense inputs of technical assistance and some financial support can make significant changes in the tobacco epidemic). Risks: The tobacco industry will lobby heavily against policies to protect the public from the tobacco epidemic, and they have exponentially more resources than we do. There is also political uncertainty in most of the partner countries, that will affect their ability to work in tobacco control. SUMMARY OF TARGETS AND/OR INFORMATION ON CROSS‐CUTTING THEMES CPB Partner: HealthBridge. Overseas Partner Organizations: Work for a Better Bangladesh (WBB), Resource Center for Primary Health Care (RECPHEC) in Nepal, S.O.S. Tabagisme in Niger, Friends of the Earth in Nigeria; and Thai Nguyen Health Department, the Vietnam Committee for Smoking and Health, and the Thai Nguyen Peopleʹs Committee in Vietnam WID&GE Millions of women will come into contact with our mass media messages about the harms of tobacco control. Some will be

motivated to stop using tobacco and to encourage the male members of their household to quit, or at least not to smoke around the children. A portion of the millions of women who live with poor male tobacco users will benefit from improved living conditions when the men stop purchasing tobacco. Women staff of NGOs will benefit from training and from improved access to materials with which to work.

ENVIRONMENT No adverse environmental effects are anticipated in this proposed project. The environment will benefit due to more smoke‐free places, less indoor air pollution, and less disposal of tobacco‐related rubbish (butts, packs, cartons).

PUBLIC ENGAGEMENT

PowerPoint presentations and videos will be created about our programmes. Our project will be described and materials be made available on our websites. Reports will be distributed at international meetings and conferences. Materials about the project will be included in HealthBridge promotional events.


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Appendix B: CIDA Declaration Documents


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Appendix C: Final Evaluation Report, Bangladesh

Background WBB Trust has been working on tobacco control since its founding in 1998. From July 2003 through December 2006, WBB has been part of the six-country programme, “South-to-South Collaboration and Capacity Building for International Tobacco Control”, or South to South (S2S) for short. The programme received technical and financial assistance from HealthBridge (formerly PATH Canada) and financial assistance from CIDA. Prior to that programme, WBB also received two years of CIDA support for our tobacco control work.

WBB’s main activity on tobacco control in the past has been raising public and government awareness of the need to pass a comprehensive tobacco control law. Following passage of the law in March 2005, we changed our focus to law implementation and passage of the rules to accompany the law. The passage of the law was made possible by the concerted, joint efforts of NGOs throughout the country working in close partnership with the Government of Bangladesh and the WHO.

Many steps were involved, from campaigning for the law, to gaining its passage, then working on the passage of the rules, and finally on proper implementation of the law. We encountered many obstacles along the way. Our attempts to overcome the obstacles proved an invaluable learning experience for us.

We learned how to carry out our work through creating a friendly, mutually-supportive environment. We worked long days and long weeks, maintaining an open house for visitors: NGO staff from throughout the country, journalists, and even government officials looking for information or assistance. We gained much information from our colleagues in the S2S network, and in our broader circle of tobacco control colleagues and friends.

Why we conducted this evaluation

We conducted this evaluation in order to compile the advantages we gained from being part of the S2S programme. We also wanted to learn what our weaknesses were, and our successes. We wanted to examine the lessons we learned about ways of working with government, about maintaining a successful network for advocacy, and how to work closely with media. By conducting this evaluation, we hoped to gain insight into these areas, and gain a better understanding of how well we really did over the course of this programme.

We also hope that this evaluation will prove useful to our colleagues with whom we will work in future, to help them understand which working methods are most likely to meet with success, and how to avoid or address certain problems that arise.

The experience we gain from this evaluation will, we hope, be useful not only for our tobacco control programme, but for our other programmes as well, in gender, environment, and ecocities.


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Sources of information for this evaluation

WBB developed an evaluation form covering our main areas of work, and sent it to our partner organizations throughout the country. We also conducted in-depth interviews with several partner NGOs, and visited a local NGO to see firsthand their tobacco control work. The information collected, and a review of our activities over the three years of the South to South programme, are described in this report.

Our fields of work

In order to carry out our tobacco control work—as well as our other programmes—we focus on the following areas, all of which are addressed in this evaluation report:

Advocacy Networking (local, national and international) and capacity building Research and publications Media

Programme objectives The overall goal of our tobacco control programme is to reduce the use of tobacco products throughout Bangladesh, and to share our lessons in this field with partners in the country and throughout the world. Our specific objectives and some activities include:

By means of workshops, seminars, and other activities, build capacity of government and non-government officials to work on tobacco control law and rules.

Work for passage and implementation of a tobacco control law including a ban on all forms of tobacco promotion, creation of smoke-free public places, stronger packet warnings; increase in tobacco taxes; and ratification and implementation of WHO’s Framework Convention on Tobacco Control (FCTC).

Build the capacity of local NGOs to conduct advocacy campaigns. Increase availability of needed information on tobacco control; share such

information with media, NGOs, and government. Train local organizations to raise funds and implement projects, improve their

management skills, and carry out evaluations. Raise capacity of local NGOs in communication and networking. Involve new NGOs in tobacco control. Participate in regional meetings and listservs, and share information with people

working on tobacco control in different countries. Conduct research to promote our advocacy goals and to better understand the

status of tobacco control in Bangladesh. Work closely with media to increase their understanding of and improve their

reporting on tobacco control issues.

Key achievements during the S2S programme

Hard work is not always rewarded. But hard work that includes careful planning, and


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involves monitoring and evaluation to ensure that the work is on track, often will be. We met frequently over the course of the programme to see whether we were succeeding in overcoming our obstacles, whether new directions were necessary, and whether or not we were still on track towards meeting our objectives. Through a combination of hard work, careful strategizing, flexibility, and changes in direction as needed, we were able to achieve a number of significant achievements:

Increased the skills of officials in the Ministry of Health, Health Department, and Ministry of Law, as well as of District Commissioners, Police, and local officials, in carrying out tobacco control activities.

Successfully carried out a number of advocacy campaigns to encourage the government to take significant steps towards building strong tobacco control policy, including signing of the FCTC in 2003, ratifying the FCTC in 2004, passing a comprehensive tobacco control law in 2005, and passing the rules to accompany the law in 2006.

Helped the government to write a proposal for, carry out workshops on, and draft a three-year national plan for tobacco control, under the auspices of the WHO.

Conducted workshops to build capacity of network NGO members in advocacy, networking, media, and communications.

Wrote a number of publications to assist advocates in their tobacco control work, and to show to government officials the need to take action on tobacco control policy, and which specific actions to take. Publications covered such issues as the FCTC, implementation of tobacco control law, and the need to raise tobacco taxes.

Produced and disseminated a number of materials, particularly leaflets, stickers, and posters, to raise public awareness on tobacco control issues.

Involved many new NGOs in tobacco control activities, and worked with existing NGOs to keep them actively involved.

Created a listserv and actively communicated with the other five countries in the S2S network, including through participation in regional and international meetings; participated in other regional and international meetings, workshops, and conferences, including government and WHO meetings on the FCTC.

Conducted research before and after passage of the tobacco control law, and used the research to identify areas for stronger implementation.

Regularly shared information with media, organized seminars and press conferences, held informal meetings, taped radio programmes in our office, and shared videotapes with TV to successfully increase print, radio, and TV coverage of tobacco control issues. Such success was made possible due to efforts to establish and maintain friendly, personal relationships with many media representatives.

Advocacy The key focus of our tobacco control programme was advocacy to strengthen national laws


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and policies concerning tobacco control. Since international experience has shown that it is laws and policies which have the greatest effect in reducing use of tobacco products, our programme focused on strengthening such policies, which were essentially non-existent when our programme began.

In the course of working on advocacy, we realized the importance of establishing and maintaining a strong, close, direct relationship with government. We quickly realized that simply standing back and criticizing government actions without working directly with government to improve policies is unlikely to result in any positive change.

Our close relationship with government became possible through a combination of a friendly, personal approach; provision of various forms of assistance to government; and regular communication and information sharing. We explained to government officers the importance of passing and enforcing a tobacco control law to improve health, reduce poverty, and reduce the harm to the environment caused by tobacco production and use. We shared international experiences in law enforcement. We explained about the activities of the tobacco industry. We measured and shared public demand for tobacco control laws and higher tobacco taxes. We also shared this information with media.

After the government passed the tobacco control law, we advised and assisted on law implementation, including on calling in mobile courts to take down tobacco ads, and publishing notices in the newspaper to inform tobacco companies of their legal obligation to strengthen their health warnings.

We had two major successes in the field of advocacy: our sharing of information, and the development of close relationships with government officials and agencies. By working step by step, in logical progression, we were able to continue building on our successes and maintain our momentum.

Of course the work did not proceed without difficulties and obstacles. For example, the following problems emerged:

Many people have a negative perception of government, believing that government is inactive or corrupt. Such beliefs can prevent them from engaging in a positive, supportive relationship with government agencies. In addition, many people feel more comfortable maintaining a combative relationship with government than entering into a friendly one.

Likewise, many government officials have a negative viewpoint about NGOs, believing that NGOs are working against government interests. Government officials thus are often suspicious of entering into cooperative relationships with unknown NGOs.

Many people working in tobacco control lack sufficient information about the work, have misconceptions about what will be effective, and believe that it is possible to engage in active partnership with the tobacco industry to reduce the problems caused by tobacco.


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Government officials often change position and departments, so that after receiving information and training from us, they leave their posts, and we must again develop relationships with and train new officials, often repeatedly in a short period.

It is difficult to gain admittance into some important government offices, and many government officials find it difficult to make time for discussions with NGOs on tobacco control issues. In addition, overworked government officials may not have specific responsibility for tobacco control, and thus government responsibilities may be overlooked in the face of overwhelming workloads.

There is often a lack of coordination and monitoring of tobacco control activities, so that different people and organizations are unaware of what others are doing, and little attempt is made to evaluate progress towards meeting objectives.

While the above obstacles often made the work a challenge, we always believed in our ability to overcome existing obstacles and achieve success. Our persistence and strategizing paid off, and we were able to recruit many government officials to our cause. Many people worked with us in not only a cooperative, but friendly way. The following are some of the ways we developed and maintained close working relationships with government officials:

Identified the officials with whom we needed to work, and created a plan as to which work to conduct with which official. (Often advocacy campaigns can miscarry due to targeting the wrong person; we particularly learned this lesson in terms of ratifying of the FCTC, which was under not only the Ministry of Health, but the Foreign Ministry, without the cooperation of which, the FCTC ratification process would never have been completed.)

Explained about the need for and situation of the FCTC, tobacco control law, and the three-year, national plan for tobacco control.

Regularly updated local and national officials about progress on different aspects of tobacco control, and gained information from them on their activities. Shared specific examples such as by showing them packet warnings from different countries.

Supported different officials in various ways, such as by providing them with information; writing, typing, and distributing minutes from different meetings; and preparing a draft tobacco control law, draft rules, and a draft three-year plan.

Tried to help strengthen activities of lower-level officials, including building capacity where possible, rather than complaining about them to their superiors; always maintained friendly relationships with government. Tried to help government officials by giving them information to pass on to their superiors, to increase their status, rather than always providing the information ourselves to higher-level officials.


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Continually worked to maintain cooperation among NGOs and between NGOs, government, and WHO, both in terms of facing problems and celebrating successes.

Prepared ourselves and government officials prior to major meetings by sharing information and discussing the issues to be raised within the meeting.

Always responded to positive developments by sending out thank you letters to the responsible officials.

Identified needs of government officials and responded as well as we could; assisted officials with information on other issues as well as on tobacco.

Successes

We were closely involved with all stages of law passage, from showing the need for a law, to drafting an initial version, to working with government to refine the law and push for passage.

Worked closely with government and NGOs to indicate the importance of signing and ratifying the FCTC.

Wrote a proposal to WHO on behalf of the government to carry out a series of workshops to create a three-year national plan for tobacco control; helped organize and conduct the workshops, and create and revise the plan.

Supported local and national efforts to enforce the law, including printing sufficient copies of the law to distribute to officials throughout the country; maintained phone and other contact with NGO and government officials throughout the country to explain the contents of the law, and trained NGOs on how to work with government for law enforcement.

Helped create public awareness about the content of the tobacco control law, both through media activities and through production and dissemination of materials such as stickers.

Obstacles in our advocacy work

Initially, we encountered many obstacles in our advocacy work due to our own inexperience. As we faced these obstacles, we learned, often the hard way, how to overcome them.

Lack of information about law and legal processes. Lack of understanding of the process of drafting and passing a law. Lack of knowledge of the key people with whom to partner for law work. Lack of a well-considered plan for working with government.

Recommendations when planning an advocacy campaign

Collect the needed information on legal issues. Learn who is involved in drafting and passing laws. Coordinate activities among NGOs, media, and other involved parties.


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Building our own capacity to work on law

Much of the success of our advocacy campaign is due to our own capacity building on legal issues. Initially, due to our ignorance, we were dependent on lawyers to help us with the issues. Since lawyers themselves are very busy, they were unable to give time to law drafting, and the process was substantially delayed. In a series of meetings to decide how to address the situation, we finally decided to seek the help of our international advisor, Francis Thompson, of Non-Smokers’ Rights Association (NSRA) in Canada, and at the time a board member of PATH Canada. He prepared and sent us a draft law, with instructions how to modify the law according to our legal system. He also took great trouble to explain the aspects of the law which were unclear to us, and why he had used the language he did.

We assumed direct responsibility for translating the law into Bengali, and in the course of doing so, learned much about legal language. At the same time, we began studying other Bangladeshi laws. We had collected tobacco control laws from other countries from a long time before this, and now studied those laws intently. As a result, we gained much knowledge about legal language and the various loopholes in many existing tobacco control laws which are important to avoid.

Activities with government

Since the founding of the Bangladesh Anti-Tobacco Alliance (BATA) in 1999, NGOs had been actively involved in promoting strong tobacco control policies. As Secretariat to the alliance, WBB played a key role in coordinating NGO activities on policy. BATA played a key role in pushing for the various key clauses in the draft law: prohibition of all forms of tobacco promotion, banning of smoking in public places, and stronger pack warnings.

As a result of the lengthy advocacy campaign and our direct involvement in law drafting, we were successful in gaining a law that bans advertising, bans smoking in most public places, and mandates strong and rotating pack warnings, beginning with the warning “Smoking kills”.

At the same time, we were working to raise awareness about the FCTC and to push the government to sign and then ratify this important treaty. At the time, government officials were unaware of the existence of the treaty, and Ministry of Health officials did not know the process of ratifying a treaty. There was no coordination among the various Ministries involved in the process. Since BATA members already had international experience, and the BATA coordinator attended most of the regional and international meetings (ISMs and INBs) for the FCTC, funded by WHO, BATA was in an excellent position to help government officials understand the treaty process.

As mentioned above, the problem of government officials frequently changing jobs proved a large obstacle, with the need constantly to train new people. We kept up a steady effort to educate new officials and maintain the pressure on existing ones. We provided the officials with information coming out of every INB, and when following elections the ruling party changed, we provided the new officials with the entire set of FCTC documents,


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which vanished with the departing officials.

In addition to the work we did on the law and the FCTC, we also addressed the rules to accompany and further define the law. While the tobacco control law is essentially a set of overall measures, the rules provide the main substance, and implementation of the law was not possible until the rules were passed. We took responsibility from the very beginning to draft a set of rules and participate in regular meetings to ensure their passage. Representatives of the tobacco industry regularly participated in meetings about the rules, and did their best to ensure that the rules were watered down to insignificance, but our continual efforts to counter their arguments proved successful, and a strong set of rules were finally passed.

We were also involved in the development of the national three-year plan* for tobacco control from the onset. We drafted, on behalf of the Ministry of Health, the proposal for the development of the plan to submit to the WHO, and drafted a sample three-year plan. We helped to organize workshops around the country to discuss the plan, created presentations for the workshop, trained the facilitators, collated the proceedings, and helped turn the input into a plan. Our support to the government was awarded by the government’s greater willingness to cooperate with us on such issues as law implementation. Without our active work on behalf of the government, the government would not have been so ready to work closely with NGOs.

Our greatest success in collaborating with the government has been in our close relationship on law implementation. It is common knowledge in Bangladesh that while many laws are passed, few are actually properly implemented. Aware of this situation, we worked hard to ensure that the fate of the tobacco control law would not be the same as that of others gathering dust. We published 25,000 copies of the law and the rules, and disseminated them to government officials throughout the country. As a result, many mobile courts were organized to enforce the law. We trained our network members to work with us in regularly monitoring law enforcement and reporting violations to concerned government officials. As a result, the tobacco control law is one of the best-enforced laws in the country.

Planning

Following study of the activities of the tobacco industry, NGOs, media, and government officials, we created a detailed, comprehensive workplan. The study that preceded the development of the plan was critical to its viability. The plan coordinated the activities of different sectors, and ensured regular communication with different stakeholders. For example, when the tobacco companies protested government plans for strong pack warnings, we informed media of their resistance. The close relationship with media was

* Initially this was a five‐year plan, which we drafted and worked on, but eventually a decision was made by other parties to tighten the time period to three years.


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critical for maintaining pressure on government.

“WBB has been extremely successful in carrying out tobacco control work. Among its major successes are the passage of the law, the signing and ratification of the FCTC, the development of the national three-year plan, and the creation of a platform for NGOs to work together.” --Rafiqul Islam Milon, MANOBIK (anti-drug organization)

Networking When WBB began working on tobacco control, we quickly realized that it would be impossible to gain any major achievements if we worked alone. As a result, we were keen to establish a strong network. Even before founding WBB, we began meeting with other NGOs working on tobacco control. Within less than a year of establishing WBB, we had started the Bangladesh Anti-Tobacco Alliance (BATA), with WBB serving as Secretariat. BATA members were critical for all our advocacy campaigns and other activities, including working for law passage and implementation, and for signing and ratifying of the FCTC. The existence of an alliance greatly increased our perceived importance in the eyes of government, whereas an NGO acting alone would have had much more difficulty collaborating with important officials.

We understood our coordination activities as going beyond ensuring communication and collaboration among BATA members and government. We also took an active role in building the capacity of BATA members to work effectively on advocacy issues. Beyond BATA members, we also created a network of hundreds of interested NGOs throughout the country, with whom we also maintained regular communication, and and whom we guided in advocacy activities.

Goals of our networking activities

Strengthen tobacco control activities at the local level (public awareness, law monitoring and implementation).

Maintain pressure on local and national officials from throughout the country and at different levels.

Ensure national coordination of local-level advocacy activities. Build capacity of local activists on advocacy, networking, media, and documentation,

and on tobacco control issues overall. Monitor activities of the tobacco industry and of law implementation.

“WBB has been extremely effective in its tobacco control work. WBB has provided the basic support that is needed for the work, including a conference room, media support, fax and internet communication, provision of technical assistance to national government and on an international level, and skill building. As a result, WBB has made it easy for other NGOs to work on tobacco control.” --Kuheli Mustafa, Secretary General, Welfare Association for Cancer Care (WACC)

“WBB has an international focus. WBB has a good relationship with government, and


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coordinates GO-NGO activities. As a result, government gives priority to WBB, and regards WBB as the key NGO on tobacco control. A country-wide network has resulted. With very little time, they can organize an activity wherever they wish. They have trained volunteers who help with other programmes as well as tobacco control.” --Enait Hossain, Executive Director, SCOPE (Barisal)

National activities

WBB coordinated activities of local NGOs, and conducted follow-up, to ensure a coordinated national programme. Our activities included:

Raising public awareness of the need for tobacco control, by assisting and coordinating activities of network members.

In order to put pressure on government at key times, worked with local NGOs to organize demonstrations demanding policy measures.

Coordinated letter campaigns to thank local and national government officials for positive actions taken on tobacco control.

Organized skill-building workshops at the divisional and national level. Ensured celebration of World No Tobacco Day at the local and national level,

including seminars and colorful rallies.

Local-level activities

The organizations with which we have worked at the local level include many dedicated, hard-working individuals with whom we have developed close, friendly relationships over the years. They have demonstrated significant social responsibility and a positive attitude to the ability of NGOs to bring about change.

They have been happy to receive various kinds of assistance from WBB, mostly non-financial, indicating their interests are for the betterment of the country, not their own financial gain. Their friendly dedication meant that much work could be done quickly and effectively. Although we were only able to provide extremely small amounts of financial assistance* and limited materials, they worked with great dedication to achieve change. Their activities include carrying out different programmes, developing relationships with local officials, providing local officials with key information, participating in letter campaigns, and disseminating materials to a local audience.

Local-level activities

Capacity building of local NGOs on tobacco control law, FCTC, rules, three-year plan, law implementation, media advocacy, networking, and documentation.

* We were limited not only by our budget, but out of fears of inspiring jealousy and reliance on funding, where many activities can be carried out essentially for free. Providing only very limited financial support to network members was thus perceived as a strategy to ensure sustainability of our national network.


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Advising and supporting local NGOs on building relationships and working with local government officials.

Explaining how to be involved in law monitoring. Building networks among local NGOs. Printing stickers with the names of local NGOs to promote both the NGO itself

and tobacco control messages. Regularly providing local NGOs with updated information. Regularly maintaining communication with local NGOs and responding to their

questions and needs. Maintaining friendly relationships through sending of cards and calling on holidays. Keeping an open-house environment in our office, where local NGO workers can

drop in at any time without an appointment and be guaranteed a friendly reception, a meal, and meetings with our staff. (Some NGO workers use our office as a resting-place, restaurant, and office, using our computers and office space to answer e-mails or catch up on their work.)

Publishing activities of local NGOs in our quarterly BATA newsletter and distributing it to government and NGOs throughout the country.

Providing local NGOs with publications containing specific guidelines for their work. Involving local NGOs in conducting nationwide surveys on different issues. Co-organizing seminars and demonstrations to create public awareness at the local

level. Co-organizing local activities for World No Tobacco Day. To encourage implementation of law and FCTC, coordinating letter and media

campaigns, and carrying out direct and telephone communication.

Achievements

Creation of a strong, active, and friendly network throughout the country. Attention and priority given to tobacco control and law implementation throughout

the country. Involvement of local government officials in tobacco control activities. Creation of many strong activists at the local level. Coordination of local and national-level activists. Provision of information from throughout the country to the national government. Regular law monitoring throughout the country. Collection of information on barriers to law enforcement at the local level.

International level

Due to our strong international networking, we regularly exchanged information with activists in other countries. This enabled us to share our lessons learned, as well as learn from our colleagues. The friendly nature of the collaboration also helped us stay motivated in difficult times. WBB is now well-known internationally for our work in tobacco control.


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Capacity building for network members

In order to ensure that partner organizations have the skills to engage in effective tobacco control work, capacity building is a vital activity. WBB’s investments in capacity building for network members paid off in terms of increased capacity of its network members and thus a stronger nationwide tobacco control programme.

Over the years, WBB has carried out three national and six divisional workshops. Content of the workshops included what contents of the tobacco control law should be (preceding passage), obstacles to implementation, important activities to improve implementation, raising awareness of law, what is the FCTC, why the FCTC is important and how we can work for its implementation, how to coordinate local and national activities, law monitoring, etc. As a result of the workshops, network members gained knowledge and skills for law and FCTC implementation.

In addition to conducting workshops and distributing materials, we asked our partners directly what sorts of information or skills they need to enhance the effectiveness of their work. In the first stage, we prepared information informally on the content of the law and sent to our members by letter. In the second stage, we explained ways in which the law is being violated, and asked members to send reports on the law violation/enforcement situation in their locale. In the third stage, we encouraged members to communicate with local officials to inform them about the content of the law, violations, and their role in enforcement. In the fourth stage, twelve particularly active districts were selected for more intensive activities in law monitoring and enforcement.

As a result of the above activities, local NGOs gained a strong understanding of their potential role in law implementation. WBB’s long-cherished dream of nationwide law implementation activities occurring through active involvement of local organizations thus became a reality.

“Myself and my organization benefited in many ways from participating in a number of workshops organized by WBB. I learned about tobacco control law, gained information about national and international activities, and developed a relationship with government and non-government organizations, with whom to collaborate on law enforcement. My NGO gained new status. I developed working friendships with a large number of people, and strengthened relationships with many NGOs, my NGO became known to many people, and the capacity of the NGO increased.” --Rafiqul Islam Milon, President, Manobik

Network organizations are our strength

WBB Trust gives much time and some financial support to its members. As a result of WBB’s investments, the network is now strong and active. As a result of the network:

150 letters were sent to the Ministry of Health for law passage; 8,000 postcards were sent to the Ministry of Health for ratification of the FCTC; 50 people met directly with their Member of Parliament to ask them to support

the tobacco control law;


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33 activities were carried out in 2003 to support law passage.

Clearly, no single NGO could have carried out so many activities alone. At present, network members are busy with law monitoring and implementation activities. With very little expenditure, we now have NGOs working actively in 36 districts.

According to newspapers, the tobacco control law is being implemented in 18 districts, and in some districts mobile courts have been called out. In addition, 1,184 branches of the government bank, Sonali Bank, became smoke-free. Three locales stand out for exceptionally strong law implementation activities: removing all tobacco billboards and signboards, and making public places smoke-free.

WBB’s ability to work effectively at the national level and support the government in law implementation would not have been possible without the nationwide communication, advocacy, and materials sharing made possible by our strong and well-coordinated network.

“As a result of participating in WBB’s workshops, we learned 100% how to implement the tobacco control law. Not only did we learn a lot, but we had a lot of fun. As a result of working together on implementing the law, we developed strong relationships with many other organizations, and as a result, my NGO is now very well-known.” --A.T.M. Shaidul Islam, Executive Director, RAAC

How we support our network

BATA does not provide its network members with financial support, and WBB only offers very limited financial support to selected members. Most organizations work on tobacco control as voluntary activities, rather than as part of funded projects. But the many forms of support we provide to our network are significant to our members. In addition, our efforts to build strong, mutually-supportive relationships with individual members have paid off. The kinds of support WBB and BATA provide to the network include:

Printing stickers and leaflets with the names of local members, and providing the materials to them;

Providing posters and signboards; Regularly offering advice on the work; Regularly sharing our publications; Helping to build strong relationships with local officials; Involving local NGOs in national-level activities; Determining the sorts of activities of which they are capable and encouraging them

to take such activities on; Inviting them to attend skill-building workshops; Putting their organization’s name on TV spots and short videos to air on local TV or

at local programmes; Helping NGOs seek funds, including advising on grant writing; Regularly sending thanks letters for their activities.

“WBB provided important support to the government by printing the law and accompanying


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rules, and sending them to officials throughout the country. WBB also helped ensure that all involved officials received letters encouraging their active participation in tobacco control law implementation. Such activities were vital to ensuring the level of awareness needed to implement the law effectively.” --Kuheli Mustafa, Secretary General, WACC

Other network activities

Significantly, once an active network exists, communication between members assists not just the tobacco control activities, but other work as well. As members become friends, cooperation is greatly enhanced, and all aspects of an organization’s work improve. Examples include:

Better sharing of resources; for example, one NGO has resources that are needed by another. Before joining the network, no communication existed; now they are able to share resources efficiently.

Providing information on where to gain funding, information, and capacity building opportunities for other programmes, such as HIV/AIDS; providing of references to partner NGOs to help them avail of such opportunities.

Providing media support including writing of press releases and building of a media network; helping with report and letter writing.

Raising self-esteem of members of small NGOs by treating them in a warm, friendly way on their visits to Dhaka and at all other occasions.

Support with funding

WBB Trust has helped member organizations gain funding from various agencies by sharing information about funding opportunities, assisting in proposal writing, and helping in implementing projects and writing reports. As a result, various BATA members received funding support from the WHO’s Channeling the Outrage, as well as grants from UICC and the Government of Bangladesh. In order to increase the chances of other NGOs receiving the support, WBB has on occasion refrained from submitting our own funding application.

For instance, Manobik received support from WHO for its programme “Doctors Against Tobacco”, with much in-kind support from WBB and HealthBridge. In all, nine network organizations received WHO support, with WBB’s assistance. As a result of receiving these small grants, their chances of receiving future financial assistance increased. WBB and HealthBridge have also helped Manobik seek funds and implement a research programme, funded by the government, on the effect on the poor of increasing tobacco taxes.

In addition to direct funding, WBB has put organizations into touch with international opportunities for scholarships to attend conferences and workshops, arranging for both NGO and government officials to attend World Conferences on Tobacco or Health, Asia-Pacific Association for the Control of Tobacco (APACT) regional conferences, and workshops on women and tobacco and the FCTC.


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Our support to capacity building of local NGOs and individuals

In addition to supporting tobacco control activities specifically, WBB also assists NGOs with a range of other activities, encouraging the creation of a friendly, mutually-supportive environment. We provide in-house training support for young staff and volunteers of partner NGOs at the WBB office. Subjects include IT, planning a project, writing a proposal, drafting a budget, report writing, documentation, internet use, media, and collaboration with other NGOs. The training is mostly hands-on; after explaining how to do a task, we give the trainees the responsibility of carrying out the task themselves, providing support as needed. While this is very time-intensive for WBB staff, it does result in a significant increase in skills on their part.

Comments of those receiving training working in WBB

We asked volunteers at WBB to provide comments on their experience. Overall, they were very enthusiastic about the opportunities they are gaining.

“My first experience at learning to work within an organized system was at WBB. Of course without organization and systems, no work is possible. Thus I am sure that this experience will have a big impact on my future. In addition, I’ve learned many other things, such as using a computer, how to start an NGO, and how to carry out NGO work. The biggest advantage of working at WBB is that I have gained direct practical experience in so many areas. Rather than learning theory, I am actually carrying out what I learn. I think it’s really important that I contribute something to my country, but that’s not so easy to do. My parents and friends used to tease me a lot for doing nothing, but now they all praise me.” --Imon Rahman, volunteer, Pratyasha (anti-drug organization)

“I have gained a lot of valuable practical experience and knowledge working at WBB. First I learned different computer programmes that help with the work; what is a network and how to work with one; how to answer network letters; how to write news for the BATA newsletter; how to work with media; and other activities needed for working in an NGO. I learned a lot of other basic practical things too, like sending a fax, creating a spiral binder, etc. It has been really helpful for me to work at WBB. By participating in different workshops and other events, I have interacted with many different people and built my own self-confidence as well as learning many things. By mixing with people from other countries when they visit WBB, I have learned about their countries and gained more curiosity about the world. This has also helped me improve my English, which is really important for me. The biggest thing for me is the friendly way in which WBB staff are always ready to help me. The friendly environment means that I am always motivated to work, and as a result, I can finish all my tasks easily.” --Eva, volunteer, WBB Trust

“I enjoy many things working at WBB, including how everyone in the office helps me with my work. I also was really excited when Mahbub bhai [Saifuddin Ahmed, Executive Director of WBB and Coordinator of BATA] won an award from WHO. When he won the award, there was a party at WBB, at which Mahbub said that the award isn’t his, but


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belongs to everyone, since by working together, the work got done. Then I thought that I also played a part in the award. That increased my motivation. My family and my organization always encourage me. At first my friends gave me a hard time about this work. Now they also encourage me, and help me in many ways.” --Faysal Ahmed, WACC

“My ideas have developed tremendously from when I started; that’s my success. My confidence has grown. I’ve had the chance to mix with all kinds of people, which has increased my skills.” --Rizia Khandaker, Manobik

Weaknesses as regards volunteers (anonymous comments)

Volunteers naturally have some complaints as well.

“I don’t see any weaknesses at WBB. From all that I see, WBB is a very strong organization. I hope it will become even more successful in future.”

“Every organization has some weak side. For me, what I have experienced as a negative is that from the beginning till now, I am still serving only as a volunteer at WBB. So in addition to my actual responsibilities, I have to do a lot of different things to help out in the office. I don’t know how long I can remain in this position. If I were hired as permanent staff, I would have a lot more motivation for the work. In addition, my costs aren’t paid to me on time, which makes it really hard for me to get by.”

“Everything has its good and bad side. I’ve noticed some things working at WBB, such as the lack of an ID card. WBB doesn’t want to take any risk, for instance, when they sent us out to put up stickers for WACC, the organization didn’t want to take any responsibilities. Even though we each represent an NGO, we’re treated as volunteers, that is, we’re given low status. Therefore, when I look to the future, I see that my work has a lot of limitations. Then I see that people who spend less time at the office get paid the same amount as I do. I also need to learn more technical skills, like using a video camera, operating Multimedia equipment, and creating a Powerpoint presentation. If staff paid more attention to such needs of ours, we would benefit a lot.”

Weaknesses of our network

Although many NGOs have been requesting membership for years, we still have no official mechanism for making new NGOs members.

Normally we are not able to make field trips to visit the local NGOs with whom we work.

We are unable to give ongoing, significant financial support to our partners. We find it difficult to maintain regular communication, due to the size of our

network and our limited staff. Network members often become inactive. Network members can suffer from a lack of motivation. Often competition and jealousy among NGOs in the same locale make cooperation

difficult or impossible.


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Comments of network members on WBB’s weaknesses

“WBB’s weakness is that while it maintains regular communication with members in Dhaka, sometimes its communication is not regular with members outside the capital.”

“WBB does not give much funding to network members, and does not provide enough training and information. There is no regional focal point. Communication with the Secretariat is individual and scattered rather than organized through a focal point. Although we’ve come together at various training programmes, we didn’t have a focal point. If there were a local committee, it would be easier to put pressure on the Ministry of Health and on tobacco companies. There isn’t enough technical or financial support for celebrating World No Tobacco Day.”

“I think WBB is mostly successful in its tobacco control work. But after law passage, it was important to hold seminars and workshops at the local level to share the contents of the law and teach people what it contains. There should have been more information sharing and materials on law to help make district committees active. There isn’t enough funding available at the local level. Local members would benefit from more funds, training, and technical support in celebrating World No Tobacco Day.”

Successes in Shalkapa and Dumki

When we first started working on tobacco control, many people said that the work was hopeless, and that we would never get a law passed. Many said that our plans were useless. But the Government of Bangladesh passed a tobacco control law in 2005, and rules for the law in 2006. The Government also ratified the FCTC and formulated its three-year plan for tobacco control. These successes demonstrate the strength of our activities, from the beginning of BATA in 1999 to the present.

We are thankful to some government officers for their support in law implementation. Their support greatly strengthened law implementation activities, and such support represents a further success of our work.

RAAC, a local organization in Shalkapa, Jhinaida, has been working closely with WBB Trust for years, as part of its involvement with BATA. After participating in the Second National Workshop, focusing on law implementation, RAAC made a plan to engage in law monitoring and implementation by strengthening their relationship with local officials. Their first activity was to send a copy of the law and rules, along with a letter, to local officials. In addition, WBB sent a letter with newspaper clippings on law enforcement to Shalkapa local officials, asking them to collaborate with RAAC on tobacco control. That is, having built up RAAC’s expertise on law monitoring and implementation, WBB supported RAAC in this role by recommending them to local government.

RAAC then kept the local officials informed on the ways that the tobacco industry was violating the law. In the end, this led to the local officials taking down all tobacco advertisements in the area. They also worked together with WBB to create separate smoking zones, usually a tin shed outdoors and at a distance from the main building, to


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ensure that non-smoking areas would really be smoke-free.

RAAC, WBB, and other organizations then wrote thank-you letters to the local officials, praising them for their important contributions. They worked together to ensure publication in local and national newspapers of the positive activities of government officials in Shalkapa. The news was also published in BATA’s quarterly newsletter, which is distributed widely throughout Bangladesh to both government officials and NGOs. All this publicity generated interest in local officials in other parts of the country, including Bogra, in law implementation; officials contacted WBB for more information on how they could take an active role in law implementation in their locale, and became active in this regard.

The main official in Shalkapa was later transferred to Dumki. WBB sent him a letter requesting him to continue his positive activities in his new location. He responded positively, writing in a letter about his activities, including removing all cigarette advertisements.

Research and Publications WBB, in collaboration with HealthBridge, has conducted research and published many documents on tobacco control, including results of research, and guides on various aspects of tobacco control work. These publications have proved very useful for advocacy campaigns and as guidance to organizations newly working in tobacco control. WBB has produced the following publications*:

1. Tobacco control law: why it is needed and what to do 2. Tobacco control law: the public demand 3. Tobacco control manual 4. Hungry for Tobacco 5. Tobacco and Poverty: Observations from India and Bangladesh 6. BAT’s Youth Smoking Prevention Campaign: What are its true objectives. 7. Do you know how to quit smoking? (Quit advice) 8. What is the Framework Convention on Tobacco Control, why is it needed, and what

can you do? 9. Report on the 1st National Workshop on Tobacco Control 10. Raising the tax on tobacco products: An important solution for increasing

government revenue and public health

In addition, we have published souvenir programmes for each of BATA’s five anniversaries, containing various articles written by BATA’s members, and various publications for World No Tobacco Day. * Although some of these publications were first produced prior to South to South, the South to South funding allowed us to reprint many of our existing publications, and also to disseminate existing ones more widely.


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In addition to the publications listed above, WBB has also:

Printed the tobacco control law Printed the tobacco control rules (for law) Created many leaflets, stickers, and posters

Importance of publications

WBB’s publications on law were extremely valuable in getting the law passed and implementation work underway in Bangladesh, by raising the capacity of local NGOs to work on law passage, and to educate government officials on the importance of law, what law should contain, and why. The publications made clear the importance of banning all forms of advertising and promotion, putting stronger warnings on tobacco packets, and making public places smoke-free.

At various government meetings, our publications were the only ones available. The publications were also put in government officials’ files and often referred to by them when they needed information on tobacco control. Even the Minister of Health gained useful information on packet warnings from our materials, and showed the illustrations in the book at meetings to argue (unsuccessfully, unfortunately) for pictorial warnings.

The publication Tobacco control law: the public demand contained information from surveys on the popularity of tobacco control law. It was, along with the other publications, vital for our advocacy efforts. Whenever we provided information on different aspects of law, we used these publications as resource or reference materials. When both NGO and government officials spoke about tobacco control law in various meetings, they frequently used our materials as their source of information. The information in the publications also made it impossible for the tobacco industry to carry their arguments forward, as their arguments were directly contradicted by the abundant information in our publications.

“The various publications on tobacco control have proved very useful for both passage and implementation of the law.” --Rafiqul Islam Milon, President, Manobik

“I have received various publications from WBB. We received a lot of support in carrying out our activities from all these materials. In addition, WBB’s reports on various workshops have made it easier for us to gather information from those workshops. Our knowledge for the work has increased significantly from their publications.” --Kuheli Mustafa, General Secretary, WACC

Media activities Given the ease with which one can reach both a general audience and policymakers through media, WBB has always placed great importance on media advocacy. Since passage of the law, media has covered various aspects of tobacco control, including the law, smoke-free places, tax increases, activities of the tobacco industry, and other issues such as nutrition and economics. We also addressed these issues in our press releases and communications with media.


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Goal of our media activities

Ensure regular media attention to the problems of tobacco use and the viability of policy-based solutions to reducing the problems.

Raise awareness among policymakers and the public of the existence and importance of tobacco control laws, the rules, the FCTC, and the need to raise taxes.

Educate people about the existence of tobacco control activities and our successes.

Our media-related activities include:

regular communication with media house representatives, sending of materials, sharing of other information, writing articles for newspapers, providing information on non-health aspects of tobacco, lending media support to other organizations, such as by sending their press

releases for them.

WBB maintains documentation on all tobacco-related news items, collecting news clippings and sending them to government officials and to network members who were responsible for getting the coverage. This documentation covers much of the country, thanks to the activities of our network members. We also collect international coverage, and documentation of tobacco advertising and other illegal activities of the tobacco industry.

Why media publishes our press releases

Some journalists already have a positive inclination towards tobacco control. We cover various angles, so that journalists find information that is related to

their interest, such as law, tax, politics, ... Some journalists became interested and learned about the topic through attending

our workshops, seminars, and press conferences. We put a lot of time into maintaining a friendly relationship with a wide range of

journalists, and keep in regular contact with them. We regularly share a wide range of information with journalists. We provide information and support to journalists on issues other than tobacco

control. When we don’t have answers to journalists’ questions, we seek out the information

and put journalists in touch with other important people, like government officials and other NGOs.

We invite journalists to various personal events (wedding anniversaries, birthdays) to encourage a friendly relationship.

We send journalists holiday greeting cards.


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We regularly organize events specifically for journalists, to share opinions and provide useful information.

We make plans to celebrate various National and International Days with journalists.

We often provide ready-written articles to journalists for publication.

Electronic media

At the beginning, we mostly focused on print media, and were very weak at electronic media (radio and TV). Early on, there were very few TV channels, so it took a lot of time and thought to gain their attention. Over time, the number of media outlets (particularly private TV channels) greatly increased, allowing us to make plans to increase our access to electronic media.

Since it is very expensive to access electronic media through traditional channels, we spent a lot of effort in looking for other ways to access them. For instance, we tried to get existing programmes such as talk shows to mention tobacco control, rather than organizing our own event. We made TV spots and sent them to various channels to air as public service messages. As a result of our letters requesting them to air the spots, many did so. We also built personal relationships with various TV producers, who then invited us to speak in programmes they were organizing on tobacco control.

We also sometimes sent CDs of our programmes to TV channels for airing, as well as inviting TV channels to all our organized events, such as press conferences and outdoor demonstrations. We provided TV journalists with information and footage when they requested it, and made special offers to journalists with whom we have particularly close relationships for exclusive information and footage.

Bangladesh Betar, the national radio station, is listened to by a considerable portion of the population each day. Thanks to the development of a strong personal relationship with producers at Bangladesh Betar, we now regularly organize radio talk shows in our office, with the radio people coming to tape the programme.

Another important and often neglected medium is cable TV networks. Although the channels may be small, the population of Bangladesh is so large that they can still be used to reach tens of thousands of people. We provided local members of our network with TV spots, ads, and other footage to air, with their name added to the programme, so that they were encouraged to push strongly, and often successfully, for the airing of the spots at minimal or no cost.

The biggest barrier we have faced to gaining more coverage by electronic media is the amount of money involved. In order to overcome this barrier, we engaged in a wide variety of tactics to gain free or minimal-cost coverage. We were successful, largely due to our efforts to develop close personal relationships with media personnel, to keep regular contact with them, and to provide interesting and useful information and footage. As a result, we gained the equivalent in media coverage of vast sums of money.


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Results

An increase in positive coverage of tobacco control law, the FCTC, tobacco tax, the national three-year plan, and law implementation.

An increase in media personnel understanding of tobacco control issues. Strong personal relationships with media personnel. A lot of coverage for very little money, including regular coverage of tobacco

control on radio and airing of short spots and other programmes on TV.

Final words We gained many successes in our work between 1999 and 2006, and particularly during the S2S programme, for which our previous work served, in many ways, as a preparatory phase. The value of the work cannot be measured in economic terms, and would not have been possible without the extraordinary efforts of our team, regularly working six-day weeks and staying in the office till 9 pm, essentially on a double shift as we pursued various opportunities to gain attention and importance to the cause.

A second important factor was the teamwork, both within WBB and throughout our network. Tobacco control staff at WBB regularly met to discuss strategy, obstacles, and progress, and other staff at WBB regularly contributed to the work of the tobacco control team. The friendly relationship with network members meant a regular stream of visitors into our office, especially in evenings and on holidays. Work that would otherwise have been far more difficult and potentially unpleasant was lighter due to the friendly relationships among staff and our colleagues.

WBB also benefited from in-house assistance provided by HealthBridge’s Regional Director, Debra Efroymson. Working out of WBB, Debra was regularly available to provide feedback into a number of WBB’s programmes. Debra also contributed to international sharing of WBB’s experiences through her various publications, which frequently cited examples from WBB and other South to South partners. Examples include Debra’s contribution to guides on implementation of smoke-free policies distributed at the World Conference for Tobacco and Health, the guide Using Media and Research for Advocacy: Low Cost Ways to Increase Success, and her participation as speaker and trainer in various regional and international conferences and workshops.

The lessons we have learned in carrying out our tobacco control programme have proved invaluable for our other work as well. The tobacco control team at WBB provides much guidance and technical assistance to other programmes in their advocacy campaigns, and performs a similar service to other NGOs in our network. For instance, the lessons learned on advocacy were essential for our successful advocacy campaign for rules to limit noise pollution, and for current efforts to implement those rules. What we have learned will strengthen all our future advocacy works, as we attempt to ensure that Bangladesh becomes a better place for all in future, in terms of health, environment, poverty reduction, and quality of life.


HEALTHBRIDGE

Appendix D: Tabac et pauvreté au Niger – Résultats d’un récherche

Association SOS Tabagisme Niger

TTaabbaacc eett ppaauuvvrreettéé aauu

NNiiggeerr ((RRééssuumméé))

NIAMEY NOVEMBRE 2003

Tabac et pauvreté au Niger

Par Ibrahim MAÏGA DJIBO, Sociologue Sous la direction de Inoussa SAOUNA, SOS Tabagisme Niger

Niamey 2003 TABLE DES MATIERES Sigles et abréviations Remerciements Préface Présentation sommaire du Niger Note méthodologique Résumé INTRODUCTION GENERALE PREMIERE PARTIE : FACTEURS DE LA CONSOMMATION DU TABAC 1.1. La percée du tabagisme dans les pays en développement 1.2. Les tactiques de l’industrie du tabac au Niger 1.3. Les raisons de fumer DEUXIEME PARTIE : TABAGISME ET SITUATION SOCIO-ECONOMIQUE 2.1. L’âge 2.2. Le niveau d’instruction 2.3. Le niveau de revenu 2.4. La connaissance des méfaits du tabac 2.5. Le nombre de repas dans la journée TROISIEME PARTIE : CONSEQUENCES DE LA CONSOMMATION DU TABAC ET PROPOSITIONS 3.1. Conséquences sanitaires 3.2. Conséquences sociales 3.2.1. L’exposition des femmes et des enfants à la fumée des cigarettes 3.2.2. La sous-alimentation 3.3. Conséquences économiques 3.3.1. Les pertes liées à la contrebande 3.3.2. Le rôle de l’Etat 3.3.2.1. La réduction de la demande 3.3.2.2. La réduction de l'offre 3.3.3. Les pertes des fumeurs et la réorientation des revenus 3.4. Le rôle des Corps de la santé 3.5. Propositions aux ONG CONCLUSION BIBLIOGRAPHIE ANNEXE

Sigles et abréviations ANPSP : Association nigérienne pour la promotion de la santé publique ASH : Action on smoking and health BAT : British American Tobacco BBC : British Broad coasting Corporation BTH : Bulgare Tobacco Holding CCLAT : Convention Cadre pour la Lutte Antitabac CEG : Collège d’Enseignement Général CMPC : Connaître mais ne pas pouvoir citer CNOU : Centre National des Oeuvres Universitaires CPC : Connaître et pouvoir citer DGD : Direction Générale des Douanes DMMC : Dépenses moyens mensuels de cigarettes DSRP : Document de stratégie de réduction de la pauvreté DUPCR : Délai d’usage de la première cigarette après le réveil ENSP : Ecole nationale de santé publique FMI : Fonds monétaire international NC : Niveau de connaissance NCCJ : Nombre de cigarettes consommées par jour NR : Niveau de revenu NRJ : Nombre de repas dans la journée NSP : Ne sais pas OCDE : Organisation de coopération et de développement économiques

OMS : Organisation mondiale de la santé ONG : Organisation non gouvernementale ORTN : Office de radiodiffusion et de télévision nationale OTAF : Observatoire du tabac en Afrique francophone PAS : Programme d’ajustement structurel PATH : Programme for appropriate technology in health PIB : Produit intérieur brut PNSM : Programme national de santé mentale PUF : Presses universitaires de France RFI : Radio France international RMM : Revenus moyens mensuels SITAB : Société ivoirienne des tabacs SNI : Sans niveau d’instruction SNIR : Société nigérienne d’importation et de réexportation de tabacs SNIS : Système national d’information sanitaire TA : Tranche d’âge TM : Travailleurs manuels TMC : Tobacco Marketing Consultant UE : Univers de l’enquête UICC : Union internationale contre le cancer VA : Valeur absolue VR : Valeur relative WHA : World health assembly

Remerciements SOS Tabagisme-Niger tient à témoigner toute sa reconnaissance à l’endroit de toutes les personnes qui, de près ou de loin, ont contribué dans le cadre de l’élaboration de ce document. Nous tenons particulièrement à adresser une motion de remerciements à Debra EFROYMSON et Sylviane RATTE, respectivement du PATH Canada et de la Ligue nationale contre le cancer de France, pour leur soutien constant. Nos remerciements vont aussi à l’endroit de :

• Maître Karimou HAMANI pour ses efforts inlassables ; • M.M. Abdoulsalam ABOUBACAR et Aboubakar INNOCENT pour avoir accepté de

lire notre travail et de lui apporter les corrections nécessaires.

Nos remerciements vont enfin à tous les camarades de la lutte antitabac qui ont participé à ce travail, en particulier :

• M. Salifou SALIFOUIZE • M. Farouk HAMZA SALOUM

Préface Voici des siècles que les gens s’adonnent à la consommation du tabac, mais ce n’est qu’au XIX

e

siècle que l’on a commencé à fabriquer des cigarettes en grande quantité. Depuis, l’usage s’est répandu à une échelle vertigineuse, puisqu’un adulte sur trois, soit environ 1,1 milliard de personnes fument dans le monde et, d'ici 2025, ce nombre devrait dépasser 1,6 milliard. D’ici 2030, le tabagisme tuera 10 millions de personnes par an ; ce qui le placera en tête de toutes les causes de décès dans le monde. Sept millions de ces décès se produiront dans les pays pauvres. Ainsi, tandis que les riches renoncent à fumer, cette habitude gagne de plus en plus les pauvres.

Comme on peut le constater, l’épidémie du tabagisme est incontestablement une des plus grandes menaces pour la santé des populations du monde.

Si la contribution du tabac envers la maladie et la mort est bien connue, une attention moindre est portée sur la manière dont le tabac accroît la pauvreté. Chez les pauvres, l'argent dépensé quotidiennement pour se procurer du tabac représente une ponction quotidienne sur les maigres ressources familiales. Pourtant, dans un grand nombre de pays, c’est précisément les plus pauvre qui fument le plus. Cet aspect très important des conséquences de la consommation du tabac qu’est la pauvreté a été longtemps négligé au profit des questions sanitaires. Or, le tabac, au-delà de son caractère délibitant, est un grand facteur de paupérisation des populations. Malheureusement, cette préoccupation n’est pas prise en compte dans les plans de développement des pays. Une analyse succincte du DSRP (Document de Stratégie de Réduction de la Pauvreté) au Niger en est une illustration.

Ce document qui est le fruit de plusieurs mois de recherche et de réflexion apporte des éléments d’information et d’appréciation permettant de mesurer la contribution du tabac dans la paupérisation des populations au Niger. Il fait également des propositions à tous ceux sont engagés dans la lutte antitabac. C’est donc une modeste contribution de SOS Tabagisme-Niger afin non seulement de sensibiliser les populations mais aussi et surtout d’amener les autorités politiques et la société civile à prendre en compte le problème du tabagisme dans tous les plans de développement.

SAOUNA Inoussa Président de SOS Tabagisme-Niger

Secrétaire Permanent de l’OTAF

Présentation Sommaire du Niger

• Situation Physique La République du Niger se situe en Afrique Occidentale. Elle est limitée :

- A l’Est par le Tchad, - A l’Ouest par le Burkina-Faso et le Mali, - Au Nord par l’Algérie et la Libye, - Au Sud par le Bénin et le Nigéria.

Pays enclavé dont le port le plus proche (Port de Cotonou au Bénin) est à 1035 Kms de la Capitale (Niamey), la République du Niger couvre une superficie de 1.267.000Km

2. Elle

présente du Sud au Nord trois zones climatiques : la zone soudanienne, la zone sahélienne et la zone saharienne qui couvre d’ailleurs la plus grande partie du territoire. Le Niger est arrosé par un réseau hydrographique comprenant le fleuve Niger sur 500 Kms, le lac Tchad et plusieurs mares.

• Situation socio – économique Avec une population estimée à plus de dix (10) millions en 2003, la République du Niger est divisée en sept départements : Agadez, Diffa, Dosso, Maradi, Tahoua, Tillabéry et Zinder, et une Communauté Urbaine : Niamey. De 1960 (Année de l’indépendance) à nos jours, le pays a connu trois Coups d’Etat militaires (1974, 1996, 1999) et une Conférence Nationale Souveraine (1991).

Les taux de couverture sanitaire, de scolarisation et d’alphabétisation demeurent faibles bien que l’on constate une légère amélioration avec la politique des cases de santé et un village- une école des autorités de la 5

e République. On distingue huit groupes ethniques :

- Les Haoussa …………......................... 56% - Les Zarma-Songhaï …………………... 22% - Les Peulh ………………………………8,5% - Les touareg …………………………….8% - Les Kanouri …………………………... 4,5% - Les arabes, Toubous et Gourmantché… 1%

La religion musulmane est la plus pratiquée.

Sur le plan économique, le Niger a connu trois grandes périodes. A l’indépendance, l’économie était une économie rurale et traditionnelle dans la mesure où la production agricole représentait 60% du PIB.

Elle a été ponctuée par l’exploitation de l’uranium à partir du milieu des années 1970 jusqu’au début des années 1980. L’économie essentiellement agricole s’était alors transformée en une économie industrielle et marchande. La production agricole ne représentait plus que 40% du PIB qui augmentait d’environ 6% par an.

Suite à l’effondrement du cours de l’uranium, une grave récession frappa le pays et l’a amené à adopter des P.A.S soutenus par le FMI et la Banque mondiale. Mais, ces mesures d’austérité n’ont pas permis de décrisper la situation. Alors, l’économie est redevenue principalement rurale,

donc extrêmement vulnérable car dépendant des variations climatiques. De sorte que les nigériens sont pour la plupart pauvres. Le revenu moyen annuel par habitant ne dépassant guère 200 US $.

Note méthodologique En s’engageant dans l’élaboration d’un document sur le tabac et la pauvreté, l’association SOS Tabagisme-Niger voulait non seulement savoir la catégorie de nigérien qui consomme le plus le tabac mais aussi avoir une idée de la pauvreté qu’engendre l’importation et la consommation de ce produit.

Il faut d’abord préciser que le Niger n’est pas un pays producteur de tabac mais plutôt un grand consommateur. Ainsi, comme produits du tabac consommés au Niger, il y a :

- Le tabac à chiquer ; - Le tabac à priser ; - La cigarette.

Mais, cette dernière, c'est-à-dire la cigarette, constitue le produit le plus largement utilisé. C’est pourquoi, dans le cadre de cette étude, nous n’avons interrogé que ceux et celles qui l’utilisent.

Alors, pour conduire une telle étude, compte tenu du manque de statistiques sur la prévalence de la consommation du tabac au sein des populations nigériennes, nous avions pris un échantillon au hasard composé de 3 000 personnes :

- 1 000 fonctionnaires ; - 1 000 scolaires dont 5 00 élèves et 5 00 étudiants ; et - 1 000 travailleurs manuels.

Les fonctionnaires regroupent : - Les travailleurs de l’administration publique et privée ; - Les volontaires de l’éducation qui sont des diplômés servant dans le système éducatif

comme contractuels ; - Les diplômés faisant le service civique communément appelés « civicards.»

Les travailleurs manuels regroupent ceux qui exécutent des petites ou moyennes activités. Il s'agit notamment des :

- Apprentis-chauffeurs ; - Blanchisseurs ; - Cireurs ; - Conducteurs de taxi ; - Mécaniciens auto et moto ; - Transporteurs ; - Prostituées ; - Vendeurs ambulants de comprimés.

Et, compte tenu du fait que les personnes à interroger n’ont pas les mêmes réalités, nous avons élaboré un questionnaire spécifique à chaque groupe, soit donc quatre questionnaires que nous leur avons soumis après un prétest sur des groupes similaires. Ensuite, nous avons procédé au dépouillement de ces questionnaires et enfin, au traitement et à l’analyse des données qui y sont contenues.

Nous avons également eu quelques interviews avec des personnes ressources. Donc, le présent document découle de la combinaison de ces informations.

Résumé La consommation du tabac provoque le décès d’un adulte sur dix dans le monde. Dans les années 2025-2030, la proportion passera à un sur six, soit dix millions de décès par an. Ce qui placera le tabac en tête de toutes les causes de mortalité. Cette épidémie naguère observée dans les pays riches commence à se répandre dans les pays pauvres.

Pourquoi cette étude ? De nos jours, presque tout le monde est unanime sur les conséquences sanitaires dramatiques de la consommation du tabac. Mais, les conséquences économiques demeurent relativement peu connues. En effet, une relative attention est portée sur la pauvreté occasionnée par cette habitude. Alors, en s’engageant dans l’élaboration d’un document sur le tabac et la pauvreté, SOS Tabagisme-Niger veut non seulement identifier la catégorie de nigérien qui consomme le plus le tabac mais aussi et surtout avoir une idée plus ou moins précise de la pauvreté engendrée par l’importation et la consommation de ce produit. Par cette étude, SOS Tabagisme-Niger veut ainsi mobiliser les pouvoirs publics, les partenaires au développement, les organisations de la société civile et le grand public contre les conséquences socio-économiques dévastatrices de la consommation du tabac afin d’amener les autorités politiques à prendre des mesures conséquentes de lutte contre le tabac et partant, apporter sa modeste contribution à l’amélioration des conditions de vie des populations. Ainsi, d’abord, nous démontrons ce qui favorise la percée de la consommation du tabac dans les pays pauvres, les tactiques utilisées par l’industrie du tabac pour embrigader les populations notamment les jeunes et les raisons avancées par les populations pour justifier cette attitude. Ensuite, nous procédons à l’identification du niveau de consommation du tabac selon le statut socio-économique. Enfin, nous faisons un exposé sur les conséquences de la consommation du tabac et les actions à entreprendre en vue de maîtriser le fléau.

Pourquoi la percée du tabagisme dans les pays en développement ?

Depuis quelques années, le tabagisme prend des proportions préoccupantes dans les pays en développement dans la mesure où sur le 1,1 milliard de personnes qui fument à travers le monde, les 4/5 environ, soit 880 millions, vivent dans ces pays. De sorte que sur les dix millions de décès par an imputables au tabac projetés pour 2030, sept millions frapperont les pays en développement. Cette situation se justifie par le fait que dans les pays industrialisés, compte tenu des conséquences sanitaires, économiques et environnementales de la consommation du tabac et de l’exposition à la fumée du tabac, les pouvoirs publics - sous la pression des ONG et des médias - ont pris des mesures efficaces pour contrer l’avancée de ce phénomène. Suite donc à ces restrictions et compte tenu de leur intention de poursuivre leur ambition macabre, les compagnies du tabac ont pris pour cibles les pays en développement où les restrictions sont inexistantes ou faibles. Elles exploitent non seulement cette situation mais aussi la jeunesse et l’ignorance des populations qui sont ainsi assiégées par des tactiques de marketing interdites dans les pays développés.

Quelles tactiques met en oeuvre l’industrie du tabac au Niger ?

L’objectif principal de l’industrie du tabac est non seulement de conserver les consommateurs de ses produits mais aussi d’en conquérir chaque jour de nouveaux. Pour réaliser cet objectif au Niger, la publicité est le moyen le plus utilisé. Ainsi, les compagnies du tabac se livrent depuis des décennies à une campagne de publicité outrancière. Cette campagne se caractérise par

l’implantation d’affiches et de panneaux publicitaires dans les endroits très fréquentés, la distribution quasi-permanente de cigarettes et de gadgets publicitaires (Briquet, T.shirt, Casquette, Autocollant…) par de très belles jeunes filles, le parrainage des manifestations culturelles et sportives, l’organisation de jeux concours pour lancer les marques, jeux au cours desquels sont à gagner des produits pour lesquels les jeunes ont un engouement particulier et la mise en circulation de cigarettes captivantes.

Quelles sont les raisons de fumer des populations ? Les individus commencent généralement à fumer durant l’adolescence ou au début de l’âge adulte. Même lorsqu’ils sont informés, les jeunes ne sont pas toujours capables d’utiliser l’information pour prendre des décisions judicieuses. Très souvent, Les fumeurs avancent deux catégories de raisons pour justifier leur attitude. Soit ils fument car la cigarette leur joue une certaine fonction, soit ils fument sans raison apparente. Les populations avouent fumer parce que la cigarette leur procure surtout le plaisir et le courage qui est nécessaire pour l’exécution de leurs activités car ils sont souvent moins au courant des risques du tabagisme pour leur santé.

Qui fume le plus ? Parmi les populations nigériennes, les plus grands taux de fumeurs se trouvent au sein des groupes suivants :

- ceux qui sont sans niveau ou ayant un faible niveau d’instruction ; - ceux qui sont sans revenus ou ayant de faibles revenus ; - ceux qui ignorent les dangers inhérents à la consommation du tabac ; - ceux qui prennent moins de repas par jour, c’est à dire, ceux qui ont faim.

Ainsi, entre les fonctionnaires, les scolaires et les travailleurs manuels, ces derniers qui sont les plus pauvres, constituent le groupe où il y a le plus de fumeurs.

Quelles sont les conséquences de la consommation du tabac ? Sur le plan sanitaire, selon l’OMS, le tabagisme provoque actuellement un décès toutes les 6,5 secondes. Les chercheurs estiment que ceux qui commencent à fumer à l’adolescence (c’est le cas de plus de 70% des fumeurs) et continuent pendant plus de 20 ans ont une espérance de vie réduite de 20 à 25 ans par rapport à ceux qui n’ont jamais fumé une cigarette. A la base de cette situation, 25 maladies provoquées directement ou indirectement par la consommation du tabac. Le tabagisme n’épargne donc aucun organe du corps humain : de la tête aux pieds.

Cependant, l’écrasante majorité des nigériens se livrant à la consommation du tabac n’est pas au courant de cette terrible situation. Sur le plan social, alors qu’il est clairement établi que celui qui respire la fumée de tabac des autres a également un risque réel de cancer du poumon et des risques de maladies cardiovasculaires, la plupart des fumeurs nigériens exposent leurs femmes et leurs enfants à la fumée de leurs cigarettes. En outre, comme le tabac devient un besoin essentiel, la nourriture pour soi et pour ses enfants devient un luxe. Des aliments fondamentaux tels que le dépenses quotidiennes des gens. Etant donné que les pauvres fument plus que les riches, ils courent un plus grand risque de mourir prématurément du tabagisme.

Sur le plan économique, il y a deux niveaux de perte. Les pertes enregistrées par l’Etat à travers la contrebande et les pertes enregistrées par les fumeurs à travers l’usage régulier des cigarettes. Pour ce qui est des premières, il faudrait noter que le Niger n’étant pas un pays producteur de tabac mais dont la situation géographique favorise le transit du tabac, d’importantes sommes

d’argent échappent aux caisses de l’Etat par le biais du reversement et de la contrebande. Le reversement, c’est le fait de mettre des cigarettes prévues initialement pour transiter dans la consommation au Niger. Et, la contrebande, c’est le fait de faire entrer clandestinement des cigarettes sur le territoire. Certes, le reversement constitue une forme de contrebande mais cette dernière est surtout favorisée par la longueur et l’élasticité de la frontière d’avec le Nigeria. En effet, avec ses mille kilomètres de frontière avec le Nigeria, le Niger est arrosé par des cigarettes de contrebande fabriquées généralement dans ce pays ou dans les pays asiatiques au grand dam des agents des douanes.

Quant aux consommateurs, ils constituent les plus grands perdants. En effet, ils allouent une grande partie de leurs revenus à l’achat du tabac au détriment des besoins essentiels tant de leurs familles que de leur propre personne pour se retrouver plus tard avec des maladies. Ainsi, notre étude a permis de constater que les fonctionnaires, les scolaires et les travailleurs manuels affectent respectivement à l’achat des cigarettes 15%, 40% et 25%.

Que faire ? La plupart des fumeurs ne connaissant pas tous les risques qu’ils courent ou n’en assument pas le coût intégral, les pouvoirs publics sont en devoir d’estimer qu’une intervention de leur part se défend, fondamentalement pour contrecarrer l’entrée en tabagisme des enfants et des adolescents et pour protéger les non-fumeurs, mais aussi pour donner aux adultes les informations dont ils ont besoin pour faire un choix éclairé. En effet, le caractère dramatique des conséquences du tabagisme rend indispensable la conception et la mise en oeuvre de mesures visant à limiter autant que possible cette catastrophe. Dans cette optique, l'Etat a un rôle primordial à jouer : l'essentiel des mesures que doit prendre l'Etat doivent consister à réduire la demande et l'offre.

Pour ce qui est de la réduction de la demande, il s'agit de combiner les opérations suivantes.

1. Les majorations fiscales Au Niger, la cigarette constitue le produit auquel l'on a le plus facilement accès sur le marché compte tenu de son bas prix. Si la cigarette est ainsi vendue, c'est surtout parce que les compagnies du tabac ne versent pas de lourdes taxes au Trésor Public. Or, depuis belle lurette, le tabac est considéré comme l'une des meilleures sources de recettes fiscales parmi les produits de consommation. L'Etat doit alors majorer leur fiscalité. Une telle politique a des avantages certains. En effet, l'augmentation des taxes sur les cigarettes permettrait de trouver des recettes conséquentes pour le Trésor public. Ces fonds pourront être utilisés pour financer non seulement de vastes campagnes antitabac mais aussi le Programme Spécial du Président de la République. Ce programme consiste en la dotation des villages de "cases de santé" et d'écoles. Il est alors évident qu'une partie de ces taxes peut être utilisée pour non seulement équiper ces centres mais aussi mettre les infirmiers et les enseignants dans les conditions optimales de travail.

2. L'information des populations La plupart des consommateurs du tabac ne sont pas au courant des risques réels qu'ils sont en train de courir. L'Etat nigérien, garant de la santé publique, se doit alors de créer un système d'information des populations sur les effets nocifs de la consommation du tabac. A cet effet, les trois moyens suivants pourront être utilisés :

- La Radio et la télé nationales (ORTN) en vue de faire passer périodiquement des rubriques d'information sur les maladies liées au tabagisme.

- Le renforcement des missions de terrain d'information en vue de soutenir l'ORTN.

- La subvention de l'organe de communication de SOS Tabagisme-Niger (INFO-TABAC).

Toujours dans le cadre de l'information des populations, l'autre moyen à utiliser, c'est l'imposition des mises en garde de santé bien imprimées sur les paquets de cigarettes. En effet, le fait de dire aux gens que le tabac tue est très insuffisant dans la mesure où cela n'explique pas clairement comment le tabac tue.

3. L'éducation des jeunes

Elle consiste à utiliser l'Ecole comme un outil efficace de prévention de l'"entrée en tabagisme" car elle constitue un des cadres où l'on fume le plus. Concrètement, il s'agit de mettre en oeuvre un programme d'éducation antitabac à l'école. Plusieurs méthodes peuvent être utilisés. On peut par exemple l'incorporer à une matière scientifique ou à d'autres matières pertinentes ou en faire une discipline à part entière faisant l'objet d'un contrôle obligatoire des connaissances.

Compte tenu de la situation économique du Niger, la première méthode semble être la plus adaptée. On peut ainsi incorporer l'éducation antitabac aux Sciences naturelles.

4. L'interdiction de la publicité et des promotions Le tabagisme est une maladie contagieuse dont le vecteur est la publicité. En effet, la publicité et les promotions pour le tabac constituent des moyens utilisés par l'industrie du tabac pour non seulement conserver les fumeurs mais aussi acquérir de nouveaux. Il y a donc lieu de l'interdire. Et, son interdiction, pour être efficace, doit être systématique.

5. La limitation des espaces fumeurs

La dangerosité du tabac est surtout liée au fait que les fumeurs endommagent non seulement leur propre santé mais aussi celle de leur entourage. Pourtant, l'on continue à fumer dans les lieux publics (écoles, centres de santé, ministères …). Fumer, c'est certes un droit mais enfumer les autres ne l'est pas. A cet effet, l'on doit interdire totalement l'usage des cigarettes dans tous les lieux publics ou tout au moins la réglementer.

Pour ce qui est de la réduction de l'offre, étant donné que la grande majorité des cigarettes consommées au Niger découle de la contrebande, l'essentiel des mesures destinés à réduire l'offre doit être axé sur la lutte contre ce phénomène. Des quatre formes de contrebande (la contrebande de transit, le bootleging, la fabrication illicite et la contrefaçon), le Niger est victime surtout des deux premières. Par conséquent, des dispositions urgentes devraient être prises pour mettre fin à cette hémorragie financière. Ainsi, pour ce qui est de la contrebande de transit par exemple, une majoration des taxes serait salutaire.

En dehors des pouvoirs publics, la famille, les corps de la santé et les organisations de la société civile doivent aussi apporter leurs contributions.

La contribution de la famille réside tout simplement dans la réorientation des ressources allouées à l'achat des cigarettes. Il s'agit en fait pour les familles d'affecter ces ressources à la satisfaction des besoins fondamentaux tels que l'amélioration de leurs situations alimentaire et vestimentaire, l'achat de fournitures scolaires, l'achat de journaux et d'ouvrages bibliographiques.

La contribution des corps de la santé réside dans l'élimination du tabagisme de leur vie afin d'être les garants de l'abstention tabagique dans les centres de santé. La contribution des organisations de la société civile réside dans l'intégration de la lutte antitabac dans leurs plans d'action.


HEALTHBRIDGE

Appendix E: Implementing Anti‐Tobacco Statutes in Pakistan: A developing country perspective

Implementing Anti-Tobacco Statutes in Pakistan A developing country perspective Support provided by: PATH Canada

Implementing Anti-Tobacco Statutes

Dr. Ehsan Latif: 2005

1

Implementing Anti-Tobacco Statutes in Pakistan A developing country perspective Support: PATH Canada Dr. Ehsan Latif Consultant Tobacco Control



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IImmpplleemmeennttiinngg AAnnttii--TToobbaaccccoo SSttaattuutteess iinn PPaakkiissttaann AA ddeevveellooppiinngg ccoouunnttrryy ppeerrssppeeccttiivvee Contents: 1. Introduction Page 3

2. The Approach Page 4

3. STEP 1. Developing an understanding of the statutes and specific requirements required for implementation

Page 5

4. STEP 2. Dialogue with the official quarters to seek their collaboration Page 6

5. STEP 3. Sensitizing the officials and conducting trainings of the ‘Authorized officers’

Page 7

6. STEP 4. Exploring opportunities to keep the activities cost-effective Page 8

7. STEP 5. Designing and undertaking awareness raising activities Page 9

8. STEP 6. Using international days like ‘World No Tobacco Day’ for highlighting the issue and gathering popular support:

Page 11

9. STEP 7. Documenting feedback on the use of various materials used for the awareness campaign:

Page 13

10. STEP 8. Involving other anti-tobacco groups to increase the scope and geographical expanse of the work:

Page 14

11. STEP 9. Linking implementation activities with future of tobacco control in the country

Page 17

12. Recommendations for replicating the implementation plan: Page 18

13. Conclusion: Page 20

14. Annex Page 21



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IImmpplleemmeennttiinngg AAnnttii--TToobbaaccccoo SSttaattuutteess iinn PPaakkiissttaann AA ddeevveellooppiinngg ccoouunnttrryy ppeerrssppeeccttiivvee Introduction: This report tackles the issue of implementing statutes linked to tobacco control in a developing countries like Pakistan where adoption of a legislation is not directly linked to its implementation, a concept perhaps alien to the developed countries where implementation is considered a logical consequence of the adoption of a statute. In the light of the activities undertaken, this report seeks to share experiences and recommends certain steps which if followed can assist in effective implementation mechanisms for tobacco control. In my opinion, implementing social laws in developing countries remains a challenge not only for the implementing authorities but also for civil society organizations that aim to decrease the incidence of a specific factor through effective legislation and its implementation. This is true for statutes related to tobacco consumption also. The adoption of Framework Convention for Tobacco Control (FCTC), the first global health treaty negotiated and adopted by the World Heath Assembly in its 56th session, lent impetus to anti-tobacco movement across the globe, especially in the developing countries. The developing countries took a positive approach in the negotiations for FCTC and collectively took on the developed countries, home to big tobacco nations and favoring the tobacco industry and its interests. This momentum led to various policies and laws developed and adopted in these countries including Pakistan. Though the statutes adopted by the legislature of these countries conform to various provisions and clauses of FCTC, the implementation mechanisms for these remain a challenge. One of the reasons commonly cited for non-implementation is the deficient infra-structure and lack of resources and therefore even after the adoption of various policies and signing of treaties, the governments in the developing countries may not have the capacity to implement laws pertaining to tobacco consumption in a manner that could ensure a decrease in tobacco consumption. The whole exercise therefore would remains under the threat of being cosmetic. To avert a similar situation in Pakistan where the government had passed legislation for tobacco control, which encompasses underage selling of tobacco products, ban on smoking at public places and public service vehicles, restrictions on sales near educational institutions and advertising controls and to ensure that the ordinary citizen benefits from it, a project with the collaboration of PATH Canada was undertaken to document these experiences and to develop an outline for the implementation of the anti-tobacco statutes from a developing country’s perspective by assessing the validity of various methods available.



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The Approach:

The implementation of anti-tobacco statutes though a matter of concern for the civil society is the domain of the official quarters and therefore a collaborative approach was undertaken for the development of implementation mechanisms required. Consultations and input from all stakeholders including the relevant authorities, civil society organizations and people identified as ‘authorized persons’ was considered and factored in for various facets of the project. The following steps were recognized as being essential for the implementation of Anti-Tobacco statutes:

11.. DDeevveellooppiinngg aann uunnddeerrssttaannddiinngg ooff tthhee ssttaattuutteess aanndd ssppeecciiffiicc rreeqquuiirreemmeennttss rreeqquuiirreedd ffoorr iimmpplleemmeennttaattiioonn

22.. DDiiaalloogguuee wwiitthh tthhee ooffffiicciiaall qquuaarrtteerrss ttoo sseeeekk tthheeiirr ccoollllaabboorraattiioonn 33.. SSeennssiittiizziinngg tthhee ooffffiicciiaallss aanndd ccoonndduuccttiinngg ttrraaiinniinnggss ooff tthhee ‘‘AAuutthhoorriizzeedd ooffffiicceerrss’’ 44.. EExxpplloorriinngg ooppppoorrttuunniittiieess ttoo kkeeeepp tthhee aaccttiivviittiieess ccoosstt--eeffffeeccttiivvee 55.. DDeessiiggnniinngg aanndd uunnddeerrttaakkiinngg aawwaarreenneessss rraaiissiinngg aaccttiivviittiieess ddiirreecctteedd ttoowwaarrddss tthhee ggeenneerraall ppuubblliicc

aanndd ‘‘AAuutthhoorriizzeedd ppeerrssoonnss’’ ttoo aapppprriissee tthheemm ooff tthheeiirr rroolleess aanndd rreessppoonnssiibbiilliittiieess uunnddeerr tthhee ssttaattuutteess iinncclluuddiinngg ppuubblliiccaattiioonn ooff mmaatteerriiaallss ttoo rreeiinnffoorrccee tthhee aawwaarreenneessss ccaammppaaiiggnn,, iinnvvoollvviinngg mmeeddiiaa aanndd sseennssiittiizziinngg jjoouurrnnaalliissttss..

66.. UUssiinngg iinntteerrnnaattiioonnaall ddaayyss lliikkee ‘‘WWoorrlldd NNoo TToobbaaccccoo DDaayy’’ ffoorr hhiigghhlliigghhttiinngg tthhee iissssuuee aanndd

ggaatthheerriinngg ppooppuullaarr ssuuppppoorrtt 77.. DDooccuummeennttiinngg ffeeeeddbbaacckk oonn tthhee uussee ooff vvaarriioouuss mmaatteerriiaallss uusseedd ffoorr tthhee aawwaarreenneessss ccaammppaaiiggnn 88.. LLaauunncchhiinngg aann eeffffeeccttiivvee mmoonniittoorriinngg mmeecchhaanniissmm ffoorr iimmpplleemmeennttaattiioonn ooff llaaww 99.. LLiinnkkiinngg iimmpplleemmeennttaattiioonn aaccttiivviittiieess wwiitthh ffuuttuurree ooff ttoobbaaccccoo ccoonnttrrooll



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Examples of activities undertaken for various steps identified

STEP 1. Developing an understanding of the statutes and specific requirements required for implementation An initial exercise was done to develop an understanding of the two major statutes regarding tobacco control in Pakistan, namely; Prohibition of Smoking in Public places and protection of non-smokers Health Ordinance 2002’ and Printing of Health Warnings Act 1979 (Amended 2002) 1 The various clauses of these ordinances were classified according to the roles of various levels of the state to identify the target audience for these, for example those to be undertaken at the Central or the Federal level, provincial level and district level

Table I Various clauses of the Ordinance on Tobacco

S. No Section of the Ordinance Responsible authorities for implementation 1. Section 3, 4

Powers to declare no-smoking places of work or use and power to authorize one or more persons who shall be competent to act under this Ordinance

The Federal Government

2 Section 5. Prohibition of smoking and other tobacco use.

Federal Government Provincial governments District and local administration

3 Section 6. Prohibition of smoking in public service vehicles.

Federal Government Provincial governments District and local administration Police authorities

4 Section 7. Prohibition on advertisement of cigarettes, etc.

Federal Government through a ‘Committee on Control of advertisements consisting of Director General Health (Chairman) Health Education advisor (Secretary)2

5 Section 8. Prohibition of sale of cigarettes, etc., to minors. -


6 Section 9. Prohibition of storage, sale and distribution of cigarettes, etc., in the immediate vicinity of educational institutions.


7 Section 10. Display and exhibition of ‘No Smoking’ board.


1 Full text of the Ordinance ‘Prohibition of Smoking and Protection of non-Smokers health 2002, along with its rules is attached as Annex 1 2 Full names and designations given on page 9 Annex I



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Identification of priority areas in the ‘Ordinance’:

The four areas of strength identified include:

1. A complete ban on smoking in public vehicles

2. A complete ban on smoking in public transport vehicles

3. Complete ban on under age selling of tobacco products (under 18 years)

4. Ban on sales in and around educational institutions

The two areas of weakness are:

1. Partial ban on tobacco advertising

2. Cumbersome mechanism for registration of cases against violations

The focus of our strategy was therefore to enforce the areas of strengths and aim to improve the areas of weakness by highlighting the ineffectiveness of the measure by undertaking research. STEP 2. Dialogue with the official quarters to seek their collaboration: The Ministry of Health is the custodian of the ‘Ordinance’ on Tobacco, letters were written to relevant officials including the Federal and Provincial Minister (Punjab) for Health and Federal and provincial secretaries and their respective Director Generals apprising them of the plan for the implementation of the ordinance. After a consultative dialogue the Federal Ministry of Health allowed the project to use its logo on the dissemination materials being produced. This permission was significant as this assisted us in seeking permission for the display of banners and other materials in the public areas and as elaborated in the section on ‘Feedback’, the general public and institutions regarded the materials as important.



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STEP 3. Sensitization of officials and conducting trainings of the ‘Authorized officers’: The authorized officers under the ‘Ordinance’ include:

a. All members of Majlis-e-Shora (Parliament) and Provincial Assemblies in respect of sections 5,6,10,12,and 13;

b. All district, Tehsil and Union Council Nazims and Deputy Nazims and Councilors in respect of sections 5,6,10,12 and 13;

c. All officers in BPS 20 and above, in the places under their jurisdiction in respect of sections 5,6,10,12 and 13;

d. All police officers of the rank of Sub-Inspector and above, in respect of sections 5,6,7,8,9,10,12 and 13;

e. Heads of the educational institutions , in respect of the school or the institution, he or she is head in respect of sections 5,9,10,12 and 13;

f. Public transport, bus and wagon drivers and conductors, in respect of the violators in the vessel in respect of section 6,12 and 13;

g. Train driver and conductor, guards in respect of sections 6,12and 13; h. Managers of airport lounges, waiting rooms at railway stations and bus stops, in respect

of sections 5,10,12 and 13; i. All crew members aboard an airplane, in respect of sections 5,6,12 and 13; j. Managers of establishments where services are provided to the public whether for a

charge or free including the sale of goods, in respect of their own establishments, in respects of sections 5,10,12 and 13;

k. Heads of hospital and other health care establishments in respect of their own establishments in respect of sections 5,10,12 and 13;

l. Managers of restaurants, entertainment houses including cinemas, theatres, studios of TV, radio, etc in respect of their own establishment, in respect of sections 5,10,12 and 13;

As a first step, a database was developed of all the concerned authorities and a copy of the ‘Ordinance;’ highlighting their respective clause in the ‘Ordinance’ was posted. A total of 2550 letters was sent. The Health Education Cell of the Federal Ministry of Health arranged a three-day training for provincial, district and local administration officials. The participants of this meeting were similar to ones identified for training for the implementation of the ordinance on tobacco, therefore the exercise for the development of local action plans for the provinces and districts were linked to the implementation of the ‘Ordinance’.



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The participants were introduced to the various clauses of the ‘Ordinance’ and were asked to develop specific plans of section fort heir areas. The outcome of this training was a ‘Plan of Action’ for the district governments to follow for their respective districts in the four provinces of Pakistan that was incorporated in their ‘Promoting Healthy Lifestyles’ campaign to ensure finances and availability of human resources.3 The Director General Health and WHO representative were present at the final session to endorse the action plans for the implementation of the ‘Ordinance’. STEP 4. Exploring opportunities to keep the activities cost-effective Resources available as compared to the volume of work that is required with civil society organizations are always a concern especially in developing countries and the intention should be make interventions cost effective. Various kinds of training were required under the work for implementation and we tried to conduct these trainings in context of those already taking place. This approach helped us to lessen the funds required on travel of the participants as they were already traveling to the venue for a related training and also helped us to ensure that a majority of the officials were present. The collaboration for the trainings, undertaken by the Ministry of Health, helped us to reach the target audience more effectively. 3 The list of participants is attached as Annex II



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STEP 5. Designing and undertaking awareness raising activities directed towards the general public and ‘Authorized persons’ to apprise them of their roles and responsibilities under the statutes including publication of materials to reinforce the awareness campaign, involving media and sensitizing journalists: Sensitizing Media: The journalists play an important role in dissemination of information at any level and needed to be sensitized on the various clauses of the ordinance. A three-day orientation session was arranged in Abbottabad, a local hill resort by The Network for Consumer Protection to apprise the journalists of various issues related to consumer’s health. During these three sessions were dedicated to tobacco control and a range of activities were undertaken including sensitization to the issues related to tobacco control in developing countries, role of the tobacco industry in increasing tobacco consumption and information on tobacco control statutes in Pakistan. The English language movie ‘Insider’ was also shown to the journalists as an example of the tactics used by the tobacco industry. The training invited lively discussions on the impact of tobacco control on the economy of the country and agriculture and the role of the journalists in assisting the authorities with the implementation of the ‘Ordinance’. It was felt that the journalists should report to the relevant authorities for any breach of the ordinance by the tobacco industry or tobacco retailers. Public Awareness Campaign: The public awareness campaign undertaken during 2004-05 adopted a two-pronged strategy to tackle the issue of smoking in public places and public transport vehicles. On one hand the concerned authorities like heads of banks, hospitals, dispensaries and other health care establishment, education institutions, conference facilities, restaurants, offices, stadiums, gymnasiums, clubs, play grounds declared as public places and airport management, buses, wagons, trains, lounges of; airports, railway stations, bus stations etc related to public transport were contacted and posters including stickers declaring the place as a ‘NO SMOKING ZONE’



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were sent. To reinforce the message volunteers were recruited to paste the stickers and posters on various shopping malls of the focal districts of the project including Rawalpindi and Islamabad.

On the other hand radio programs were aired to apprise the public of their role in implementing the ‘Ordinance’ by not smoking in public areas and to report violations of underage selling in their respective communities. Programs were aired on FM 99, a local FM station. A total of five programs were aired in national language (Urdu) and live calls were entertained to answer various queries of the listeners. Representatives of the Ministry of Health were also present in the program along with medical specialists. Since the public transport in mainly run by private companies, a different approach was undertaken for public transport. In collaboration with the local police, a week-long road

campaign was undertaken in which banners were displayed on the most populous public transport routes. Stickers were designed and pasted on all the vehicles plying on these routes, declaring smoking in public service vehicles an offence, with the help of the local traffic police. At times stiff resistance from the drivers of these vehicles had to be tackled with care and caution. The presence of their local union officials and traffic police authorities helped in this regard again emphasizing the importance of sensitizing the local administration first before taking any practical steps.

The campaign attracted the media in which live interviews were aired on various radio channels and state run television station, Pakistan Television invited the coordinator of the Campaign (Dr. Ehsan Latif) for a forty-minute live chat show in its morning transmission that has a broad audience.



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STEP 6. Using international days like ‘World No Tobacco Day’ for highlighting the issue and gathering popular support: World No Tobacco Day was used as a means to highlight the issue and following activities were undertaken for the implementation of the ‘Ordinance on Tobacco. A research done on the impact of tobacco advertising on Youth was launched at this day linking it to future statutes required for tobacco control.

i. Press Conference at Islamabad Press Club4

The conference was covered by the following national dailies on World No Tobacco Day, 31st May 2005 including five English dailies and seven national language newspapers.

ii. Seminar at Pakistan Institute of Medical Sciences, Islamabad chaired by the Federal

Minister for Health and attended by medical professionals.

The Federal Minister of Health, who publicly acknowledged the role of Dr. Ehsan Latif in implementing the tobacco control ordinance, chaired the seminar. DG Health, Executive Director PIMS and Dr. Sania Nishtar also spoke on the occasion.

Dr. Ehsan highlighted the need for implementation of tobacco control ordinance in it true sense at national level. He apprised MoH of various steps undertaken for the implementation of Tobacco Ordinance and further steps for required for comprehensively banning tobacco advertisement on electronic and print media.

iii. Live PTV program News Morning:

Attended by Dr Ehsan Latif, alongside Dr. Khalif Bile Muhamud (WR Pakistan), and Mr Sattar Chaudhry (Health Education Consultant).

iv. WNTD Program on private channels

• Program recorded on ‘Women and Smoking’ for Radio Program on women

issues, titled ‘ Meree Awaz Sunno’(Listen to my voice) again highlighting the need to implement the ordinance for saving the women and children from the effects of second hand smoke

• Interview on GEO TV on present state of implementation of the Ordinance • Interview/Press Conference Coverage on APNA TV meaning ‘OUR OWN TV’ • FM 99 live Radio Program

4 Copies of press releases attached



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STEP 7. Documenting feedback on the use of various materials used for the awareness campaign: A survey was conducted at the beginning of the exercise to assess the awareness of the public and authorized officers about the various clauses of the ‘Ordinance’. The same team conducted the pre-intervention and post-intervention surveys. The pre-intervention survey conducted in August 2004, indicated that 16 percent of the people were aware of the ordinance. Their specific knowledge about the various clauses of the ‘Ordinance’ is given in Table I. The table also includes the results of the post-intervention survey conducted in June 2005 and indicates an overall improvement of twenty two percent, with 28 percent of people now reporting that they were aware of the ‘Ordinance’. Table 1 Awareness of Ordinance ‘Prohibition of Smoking and Prevention of Non-Smokers Health Ordinance 2002’ and its various clauses Survey population: 750 households in Rawalpindi and Islamabad districts

S.No Clause of the Ordinance Pre-Intervention Post Intervention

Yes Percent Yes Percent 1 Ordinance (overall) 120 16.0 285 38.0 2 Ban on smoking in Public places 143 19.0 370 49.3 3 Ban on smoking in Public transport 136 18.0 314 41.8 4 Ban on underage selling 41 5.4 99 13.2 5 Ban on sale in and around educational

institutions 46 6.1 76 10.1

Regarding the utility of the various materials produced including the stickers and posters, the owners of the establishments who were required to display the ‘No Smoking Sign’ reported that the size of the poster used was inadequate, as it required space, which was not available in most of the shops or decreased space for commercial advertising. The shops where the posters were dispatched through mail, out of a sample of 100 establishments only 11 percent of the shops had displayed the poster. The survey teams visited the sites on alternate days and recorded the presence of the posters and any mutilation that had occurred. Mutilated posters were recorded as lost. The life of the



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posters pasted in the public areas was also short. (Average 3 days: min: 1 day, Max: 7 days) On the other hand Stickers developed for the campaign did fairly well. The stickers were placed in shops, establishments and public service vehicles. All the vehicles were required to display the

sticker inside the vehicle. The stickers in the 150 establishments visited were pasted by 32 percent of the establishments and lasted for an average of 77 days (min: 30 days, Max: 120 days) The survey team visited randomly selected sites at two weeks interval and noted the presence or absence of the no smoking sticker.

The ‘No Smoking Stickers’ developed for the public transport vehicles carried the insignia of the Traffic Police of the respective regions. These stickers were still present in 68 percent of the vehicles after a period of three months.



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STEP 8. Involving other anti-tobacco groups to increase the scope and geographical expanse of the work: One of the fundamentals in the whole exercise was the recognition of the fact that as activists we are confined to certain geographical boundaries owing to the diverse cultures of our region, the languages we speak and the mode in which we consume tobacco. The launch of the coalition for monitoring ordinance related issues helped us in giving it a national focus and brought in expertise of people who had the knowledge of working in rural communities as well.

Objectives of the consultative process: Recognizing the crucial role that the non-governmental organizations play to influence the government bodies to develop and implement pro-consumer policies through a collaborative approach, a consultative meeting of credible anti-tobacco organizations working in different parts of the country was arranged to discuss and to join hands to support the implementation of ordinance at regional level and to further tobacco control in Pakistan in light of FCTC. The meeting was initiated on the following three point agenda:

• Discuss present status of implementation of Ordinance and share experiences • Monitoring of ordinance implementation at regional levels • Enhancing tobacco control in the light of FCTC

Discussions: Existing status of Implementation The group was unanimous on the issue of ineffective implementation of the ordinance at the district level and lack of infrastructure to enforce it. Although the implementation committees and provincial implementation plans had been formulated at the start of the implementation process yet the representatives from North West Frontier Province (NWFP) expressed absence of any such committee in NWFP5. Broadly the following conclusions were unanimously drawn after detailed discussions.

• The Federal Ministry of Health on its part has disseminated and informed all law enforcement agencies and other stakeholders throughout the country, and this dissemination has generated a positive response from authorities to implement the law but more work needs to be undertaken to bring the implementation to an optimal level.

5 NWFP was not a focal district for this work



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• Provincial and district plans of action have been made at Provincial level, yet effective implementation drives need to be undertaken.

• Complicated legal mechanisms to enforce the law and to punish violators. • Lack of political commitment at the regional level.

Monitoring of ordinance implementation at regional levels: It was agreed that the participating NGOs would be active in monitoring of implementation of Ordinance in their regions, through a well-structured monitoring methodology and then the findings shall be compiled on regular basis to be disseminated to all stakeholders, especially the Federal implementation Committee responsible for overseeing the implementation of this ordinance across the country. The reports shall also be circulated to the parliamentarians, members of standing committees on Health, Information and Law, and to the members of Federal/Provincial implementation committees constituted by the Federal Ministry of Health. Besides, the findings shall be reported in media nationally. Enhancing tobacco control in the light of FCTC Non-governmental organizations (NGOs) have played a leading role in combating tobacco use in many nations and were instrumental in ensuring that the FCTC is ratified worldwide. They now have yet another crucial role to play in treaty implementation. It was decided that anti-tobacco activists and advocates would serve as educators, communicators and sources of new ideas and information for the Government of Pakistan to translate provisions of FCTC in national legislation. The FCTC recognizes the importance of NGO involvement and NGOs will be working in partnership with the health ministry in this respect. Outcomes: Formation of ‘Coalition to monitor Tobacco Ordinance ’ The participants of the consultative session acceded to join hands in the Coalition to monitor implementation of ordinance in their respective work areas. This monitoring exercise would be undertaken on volunteer basis considering the following objectives.

• To support the government in implementation efforts • To have a direct assessment of implementation status at grass root levels. • To monitor the tobacco industry as it now seems to be targeting the rural areas of

the country.

The detailed ‘terms of reference’ for this periodic monitoring activity shall be discussed after a meeting is held in the southern region of the country from where all the participants could not attend the meeting due to various logistic reasons.



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Regional monitoring coordinators ; ( North Zone) 6 The group unanimously appointed the following regional coordinators for this exercise.

• Rahimyar Khan: Dr. Mazhar Abbasi (Human Development Foundation) • Peshawer: Dr. Saeed-ul Majeed (Pakistan Anti-smoking Society) • Mardan: Pardul Khan (Integrated Regional Development Programme) • Nowshera: M. Ishtiaq (HEDA Welfare Society) • Wana: Zafar Saleem Bangash (Al Noor Foundation) • Sargodha: Khawaja Qaiser Ayyub/Mirza M Akhtar (The HANDS) • Rawalpindi: Asim Nawaz (Umeed-e-Nau) • Faisalabad: Dr. M F Sunny (Sunny Trust) • Sahiwal: M Shafique (Lok Sujhag Punjab) • Multan: Ms. Shaista Bukhari (Womens Rights Association )

Recommendations by the Group: Appreciating the initiatives taken by the Ministry of Health, Government of Pakistan to curb tobacco epidemic from the country and recognizing the role that the civil society organizations working against tobacco have to play to help in implementation efforts and changing societal behavior against tobacco use; the participants of this first consultative session to discuss the status implementation of tobacco ordinance in Pakistan recommended that:

• The concerned ministries including law, interior, and information should play their role in implementation of the Prohibition of Smoking and Protection of Non-smokers’ Health Ordinance 2002’.

• The Provincial and district implementation and monitoring teams should be

immediately established and activated. • Situation assessment of the status of implementation of ordinance should be

conducted on regular basis to guide all stakeholders in playing their role in implementation.

• The federal government should make sure that the federal, provincial and district

implementation committees should conduct their meetings on regular basis. • District government should be actively involved in implementation activities and

appropriate funds allocated to run implementation campaigns.

6 The discussion group comprised of representatives of organizations from Upper Punjab and NWFP, designated as ‘Northern Region’. The discussions and group formations for Lower Punjab, Sind and Balochistan shall take place in a similar meeting at Karachi, subsequently designated as ‘South Zone’.



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• Institutions like educational institutions, and religious bodies should be actively engaged in implementation process.

• The civil society organizations should play an active role in monitoring the

implementation to boost the pace of implementation nationally. Follow-up:

The terms of reference for the regional coordinators and monitoring survey tools shall be finalized in July-August 2005 and shared with all the members of the group. STEP 9. Linking implementation activities with future of tobacco control in the country Undertaking research that indicates the areas for improvement, can help the tobacco control activists in presenting a strong argument for the improvement in the various clauses of a statute. The Ordinance on tobacco in Pakistan restricts the tobacco promotion activities of the tobacco industry. A research was conducted to assess the impact of these advertisements on the youth and the results were used to present a case for stronger legislation in the country.



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Recommendations for replicating the implementation plan:

1. Always make an attempt to be familiar with the law and to recognize its strengths and weaknesses. As public health advocates we tend to ignore the importance of understanding the legal language of these statutes. Understanding these statutes proved extremely helpful as we could then prioritize the areas where effective interventions could be made and areas where more research and lobbying was required.

2. Focus your strategy on the areas of strengths and aim to improve the areas of weakness by highlighting the ineffectiveness of the measure Basing your arguments on research assists you in presenting a sound argument. The research does not need to be extensive and costly. A well planned survey that takes into consideration the validity of the sample size can be indicative of meaningful results ands can help any public health advocate, emphasize the results.

3. Involve the concerned authorities at the beginning, apprising them of your plans and seek approval Though the main area of work for civil society organizations is to monitor and report various developments, this needs to be kept constructive and assertive. The people need to know that the government is behind the implementation of the law and it is not a standalone activity undertaken by an NGO as they would always challenge the validity of your actions.

4. Develop a strategy specific to your need based outcomes The areas of work need to prioritized and in our case implementation of Smoke-free work places and public service vehicles had the necessary infrastructure available for implementation of these statutes. The campaign was designed to cater to the implementation of these initially. Though other provisions like under age selling were also considered but a step-wise approach allowed us to tackle the least difficult first, helping in creating a visible impact in the society and generating discussions on the issue.

5. Develop specific materials for public awareness and always pilot them Though we piloted the materials, the size of the posters, which came out as a deterrent for shops and offices, citing availability of space as a constraint, led to few shops displaying these. Always make sure that you analyze the layout, size and content, as we tend to focus on content more than the layout or the size that in our case mattered most.

6. Remain flexible as you might have to change your game plan once you start to implement it practically Various situations ranging from security concerns to weather conditions might lead to an alteration to your game plan. Always factor these in. Another aspect is not to be



19

person dependent as officials may get transferred or changed. Always keep a record of the correspondence that can be used even if a change occurs to ensure continuity. This might sound alien to people in the developed countries but is very valid in the developing countries scenario.

7. Involve and use media effectively to reach your audience including the policy makers Politicians and policy makers in our part of the world remain susceptible to public opinion and are influenced by media appearances. Use media as effectively as possible and balance out your statements that involve media for example those used for comprehensively banning tobacco advertisements in print media.

8. Do not underestimate the need for trainings. Experienced people may not have enough knowledge to help you in your cause One of the dilemmas in developing countries is that the authorized officers under a statute may not be well conversant to the various clauses or their scope. We found the trainings of authorized persons including police officers was useful in not only getting them on board but also in mustering support for the activities we were undertaking.

9. Involve partners and other civil society organizations to broaden the scope of your intervention and to make your recommendations more relevant One of the fundamentals in the whole exercise was the recognition of the fact that as activists we are confined to certain geographical boundaries owing to the diverse cultures of our region, the languages we speak and the mode in which we consume tobacco. The launch of the coalition for monitoring ordinance related issues helped us in giving it a national focus and brought in expertise of people who had the knowledge of working in rural communities as well.

10. Always assess your interventions It is important to learn from your mistakes as well as your successes. What may sound right in a controlled environment may not be relevant nationwide. Always assess your interventions from the view of improving upon them in the light of experiences you have gained from a local intervention.



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Conclusion: Though the ordinance, ‘Prohibition of smoking at public places and protection of non-smokers health 2002’, does not encompass all the issues related to tobacco control, it still has a strong symbolic value in Pakistan as it was approved amidst intensive lobbying and opposition from the tobacco industry. Simultaneously having a tobacco control law does not serve the purpose of decreasing tobacco consumption in the absence of conscious efforts for its implementation. Implementation of tobacco Ordinance cannot be simply addressed by lobbying for appropriate interventions to facilitate the implementation, as this is an amalgam of changing smoking culture and enforcing law at the same time. Given the infrastructures available to the government for the implementation of this ‘Ordinance’ the onus of implementing cannot be left entirely at the hands of government functionaries alone. Effective and sustainable implementation requires a diverse nature of strategies that need to be instituted in partnership, possible only by a collaboration of multitude of organizations including the district administration, Police, Public Health departments, local civil society organizations, and medical associations. The civil society should therefore continue to support and collaborate with the respective departments to address the issue of implementation and to counter any moves made by the tobacco industry to keep the statutes redundant and obsolete and to coax the government not to spend scarce resources on efforts like underage selling which are difficult to implement in societies like our, and an action which can be expolited by the tobacco industry.


HEALTHBRIDGE

Appendix F: HealthBridge’s South‐to‐South Tobacco Control Program: Lessons Learned

HealthBridge’s South‐to‐South Tobacco Control Program:

Lessons Learned

Written by Debra Efroymson

Edited by: Lori Jones

Sian FitzGerald

Contributors: Akinbode Oluwafemi Pham Hoang Anh Inoussa Saouna Shanta Lall Mulmi

Shoba John Syeda Annona Rahman

HealthBridge January 2007

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Acknowledgment The South‐to‐South tobacco control program, which this document is about, would not have been successful without the contributions of far more individuals than we can name here. Our numerous colleagues and friends generously shared information, ideas, and experience.

We thus dedicate this document to the powerful, well‐organized, well‐mobilized, and increasingly successful international tobacco control community—to all the people we are so pleased to have as friends as well as colleagues.

Introduction

Tobacco use is widely recognized as a major cause of preventable disease and death. In addition, tobacco cultivation, and the production, use, and disposal of tobacco products all damage the environment, contaminating the soil, water and air with dangerous chemicals. The use of tobacco by the poor further exacerbates poverty, and with most countries being net importers of tobacco, expenditures on tobacco can be a major drain on the national economy. In order to address these issues, HealthBridge has been working on and supporting tobacco control for more than a decade in partnership with many NGOs throughout the world. As strong policies are enacted to reduce tobacco use, significant improvements in health, life expectancy, poverty reduction, and decreased environmental damage result.

As with any program, implementation involves the learning of many lessons which could fruitfully be shared with others, including those managing, advising, or funding tobacco control programs. This document attempts to share such lessons learned through HealthBridge’s South‐to‐South program.

South‐to‐South Collaboration and Capacity Building for International Tobacco Control (S2S) was a three‐year, six‐country tobacco control program supported by the Canadian International Development Agency (CIDA) and HealthBridge (formerly PATH Canada). The six partner countries (Bangladesh, India, Nepal, Niger, Nigeria, and Vietnam) are geographically, linguistically, and culturally diverse, but also had certain key points in common: all had strong tobacco control activists working under difficult circumstances with limited budgets, and none had

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strong tobacco control laws or policies yet in place. The program built on years of collaboration with many of the partners [including SOS Tabagisme‐Niger, WBB Trust in Bangladesh, Environmental Rights Action/Friends of the Earth Nigeria, Resource Center for Primary Health Care (RECPHEC) in Nepal, and Thai Nguyen Health Department, the Vietnam Committee for Smoking and Health, and the Thai Nguyen Peopleʹs Committee in Vietnam], but with three years of guaranteed support, also succeeded in vastly expanding networks in each country and greatly strengthening existing programs.

In five of the six countries, the program’s main goal was to strengthen tobacco control laws and policies through collaboration with, and advocacy of, national (and in some cases local) government. HealthBridge’s program in Vietnam focused instead on implementing the government directive making hospitals smoke‐free. The different focus in Vietnam was due to a number of factors, including the facts that the government had already banned virtually all tobacco promotion, that HealthBridge already in place programs to support the government in other policy areas, and that the government was having an exceedingly difficult time working on the problem of secondhand smoking, with even the “easiest” step, that of making health facilities smoke‐free, proving impossible to implement thus far.

In addition to the six partner countries, HealthBridge used program funds to support activities in several other countries. This included workshops in Anglophone and Francophone Africa organized by the Framework Convention Alliance (FCA), an alliance of NGOs supporting the ratification and implementation of the WHO’s Framework Convention on Tobacco Control (FCTC), and policy and law implementation in Brazil, Honduras, Indonesia, Pakistan and the Philippines.

This document presents key lessons learned through the S2S program. It is meant to be of use to those seeking to increase the effectiveness and efficiency of tobacco control funding—for donors, program implementers, and activists—by pointing to areas and approaches likely to succeed and means to increase the likelihood of such approaches.

Key lessons learned

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HealthBridge and its partners in Africa, Asia and Latin America gained much experience on tobacco control during their more than three years of collaboration. These lessons, described in detail below and illustrated with examples from HealthBridge’s partners, illustrate the importance of:

1. GO‐NGO Collaboration – There is great benefit when close, positive, mutually‐beneficial working relationships can be established, in which NGOs provide a service to governments and yet maintain the independence with which to criticize governments if they fail to act to protect health;

2. Capacity building – When done appropriately, capacity building activities can be an essential tool for building local networks and ensuring that local partners have the required skills to successfully engage in the types of advocacy work that will likely reduce tobacco use;

3. Media – In order to reach policymakers and the public, electronic and print media are essential partners. Tobacco control activists can become experts at gaining media attention and greatly improving the quantity and quality of media coverage for the work;

4. Law enforcement – It is not enough to pass a tobacco control law, if that law is not then enforced. Nor is it acceptable to place the entire burden of law enforcement on already over‐burdened governments, which often lack the capacity to do so effectively. Activists can and should play an important role in ensuring that laws are properly enforced.

5. Targeted research – While an enormous amount of research has been conducted already on tobacco—especially tobacco‐related disease—sometimes key research projects that would prove essential in gaining policymaker support for tobacco control are lacking. Activists should identify such research areas and where needed, carry out and widely disseminate the results to help achieve desired policies.

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6. Decentralization of work – Many countries are too large for the central government, or central NGOs, to effectively oversee activities and law enforcement throughout the entire country. It is thus often vital to involve local organizations and ensure their active participation in tobacco control activities that have proven to be effective at reducing tobacco use.

7. Managing a network – As an essential aspect of decentralizing work, NGO leaders must understand how to effectively manage a network, so as to facilitate cooperation. Key lessons in network management must be learned and put into practice so that networks can work more effectively.

8. Public education – While the focus of the South‐to‐South work was on policy, public education can be essential for gaining the momentum needed to ensure passage of policies, and compliance with policies once passed. The public can and should be involved as an active partner in tobacco control work, as long as the focus is on the policies that have proven to be effective, rather than entirely on public education without the support of law and taxes.

9. Managing difficult political situations – In ideal situations, stable political environments facilitate tobacco control work. However, in many cases, one must work in unstable environments where frequently changing political leaders, political clashes, and even shut‐downs make work extremely difficult. It is possible to adapt one’s working methods to adjust to the difficulties created by politics, ensuring that the work continues despite external problems.

10. Publications for international use – It is wasteful to expect activists in each country to “reinvent the wheel” in terms of learning strategies to deal effectively with obstacles placed by the tobacco industry, reluctant governments, and media. By sharing strategies and successes, activists can greatly increase the effectiveness of their work. Tiring though it is to prepare documents on such lessons, it is essential for international cooperation, sharing, and overall progress.

11. Importance of on‐going, long‐term funding – Tobacco control activists should have the freedom and flexibility to focus on their work and create long‐term plans, rather than always worrying about how to pay next month’s office rent and salaries. While seed grants and other short‐term, small projects can be of great importance, major changes in policy and enforcement will be unlikely to occur without longer‐term sustained funding that allows activists to carry out ongoing advocacy campaigns.

12. Importance of supporting sustained activities, not just capacity building/workshops – While capacity building is vital, it is not the only element needed to achieve success in tobacco control. Capacity building

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should complement, rather than supersede, the long‐term, day‐to‐day activities that create policy change.

13. Importance of supporting highly skilled local activists and NGOs rather than just “fly in the expert” – Local expertise should be recognized and acknowledged, rather than always assuming that external experts are needed. As with capacity building, international experts should complement rather than supersede local activists. Useful as the injections of knowledge can be, international experts need to be injected into existing programs with sufficient funding to ensure that activists can achieve their goals.

Each of these lessons is described in more detail below. Many more lessons may have been missed, but these represent key points to ensure greater success in tobacco control—and other programming to improve health, the environment, and assist in poverty reduction—in the future.

I. GO‐NGO Collaboration

Tobacco control work cannot be successful without strong collaboration between government and non‐governmental agencies. Since the most effective ways to reduce tobacco use are through laws and tax increases, government action is necessary; yet governments often require the support of NGOs to pass and enforce strong policies. In some situations and countries, a natural conflict appears to exist between GOs and NGOs, yet positive working relationships can also exist. One key lesson learned is that NGOs must, as much as possible, develop close relationships with government officials while still retaining the freedom to criticize those governments for specific actions or the lack thereof.

One effective way to enhance GO‐NGO collaboration is for an NGO to approach the relationship not by seeing what it wants from governments, but rather how it can assist government officials to carry out their jobs. After all, government officials have many responsibilities besides tobacco control, and are not always able to stay on top of current information. By providing assistance, information, and support to government officials, NGOs can enter into a positive, mutually‐beneficial

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relationship that greatly enhances the possibility of working closely together to advance tobacco control.

Lesson learned: Mutually‐supportive GO‐NGO relationships can lead to improved policy passage and implementation, with NGOs helping to strengthen governments while still retaining the ability to criticize as needed.

Examples: Environmental Rights Action (ERA) in Nigeria had been championing the formation of a National Inter‐Ministerial Committee on Tobacco Control. After much vigorous advocacy, the committee finally received presidential approval, and asked the Programme Manager responsible for tobacco control at ERA to represent civil society on the committee. That is, not only did the advocacy succeed in its overall goal of gaining the establishment of the committee, but through its advocacy efforts, the work of ERA itself was acknowledged to the extent that it was invited to join the committee.

RECPHEC in Nepal supports a vigorous district‐level network. One district, Nawal Parasi, conducted a successful workshop on FCTC and the Role of Civil Societies. The workshop was so successful that during it, the Local Development Officer of the district proposed the District Health Officer as the convener of the district network, the Chief District Officer as the advisor, and the leading local NGO, SAHAMATI, as secretary. That is, local government both came to the forefront of the tobacco control network and expressed their strong interest in collaborating with NGOs.

The HealthBridge Program Director in India held positions on key government committees, thanks to years of collaboration with the Ministry of Health, including serving as Member of the Steering Committee of the Government of India (which takes action on violations of the advertising regulations in the National tobacco control law) and as Member of the Presidential Task Force on Tobacco Control (the official, over‐arching body for tobacco control in India).

The Minister of Health requested the Bangladesh Anti‐Tobacco Alliance (BATA) to carry out public demonstrations in support of tobacco control policies at key points in the debate in order to demonstrate popular support for tobacco control. WBB staff members were very involved in drafting the tobacco control law and regulations, and in supporting the government through the process of FCTC ratification. WBB now supports the government in law enforcement, and will serve on the government’s national steering committee for tobacco control.

GO‐NGO collaboration in Vietnam

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Many countries have formed alliances or other groups to coordinate efforts in tobacco control. Usually such groups consist solely of NGO members. But the Tobacco Control Working Group in Vietnam has successfully brought together NGOs, WHO, UN agencies, and the Vietnam Committee on Smoking and Health (VINACOSH), the government agency responsible for tobacco control. The presence of VINACOSH in the Working Group is extremely important in ensuring communication and collaboration across sectors.

Further, HealthBridge in Vietnam has trained government officials to make hospitals smoke‐free, in a direct collaboration with the Department of Therapy of the Ministry of Health (which oversees hospitals) and the Vietnam Health Trade Union. GO‐NGO collaboration was facilitated by the fact that HealthBridge had been working with the Ministry of Health and VINACOSH for years, and that the program directly addressed a key issue faced by the government. The Minister of Health had regulated that all health facilities become smoke free, while the main role and responsibility of the Health Trade Union is protecting the interests and benefits of health professionals. Implementation of the smoke‐free policy, however, was weak; both VINACOSH and the Health Trade Union were eager to improve implementation, and thus were receptive to GO‐NGO collaboration on the issue.

Thus, a key lesson was the need to build relationships over the years, including through provision of services (offering information on various tobacco control‐related topics) and materials (stickers, reports), and through friendly exchanges during informal visits that complemented more formal meetings. A second key lesson was the need to identify opportunities within the political context: when the government had certain goals it wished to achieve but needed help, the office of HealthBridge Canada in Vietnam was prepared to offer assistance.

As an outcome of the project, the Department of Therapy decided to include “smoke‐free” as a criterion in the rating scale (counting for 2 out of a possible 100 points) used in the annual overall evaluation of hospitals throughout the country. Hospital directors take the evaluation seriously, as it indicates the performance of the director and his team. This success ensures the sustainability of the program even after HealthBridge withdraws, as the Ministry of Health will continue to

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monitor whether or not hospitals are smoke‐free, and directors will be motivated to comply with the government guidelines.

Lessons learned in developing collaboration with partners:

1. Identify the appropriate agency or organization to carry out effective work in tobacco control. In the case of Vietnam, since the Department of Therapy had responsibility for developing good practice in hospital management and the Health Trade Union was responsible for protecting the interests of health professionals, they were natural partners for the program.

2. If the coordinating agency is foreign and/or project‐based, as long as it maintains control of the project, sustainability will be difficult or impossible to ensure. It is vital for different agencies, particularly local organizations that have ongoing responsibility for the work, to collaborate effectively. This includes developing a sense of ownership of the project by the local partner. Ownership in turn will increase greatly the chances of success and sustainability of the project/program.

3. Identify opportunities to make the intervention sustainable after the close of the project. In this case, HealthBridge succeeded in advocating government to include being smoke‐free as a criterion in the hospital rating scale.

4. The work can often be extended without additional resources by seeking opportunities to collaborate with other projects; for example, integrating smoke‐free health facilities into an ongoing project of the national or provincial Public Health Associations.

Pressure and partnership in Nepal

RECPHEC’s relation with the government consists of both pressure and partnership. For years it has been advocating the government to pass a Tobacco Control Act and to ratify the Framework Convention on Tobacco Control. But RECPHEC’s relationship with the government is also a partnership. Government representatives participate in different meetings and workshops organized by RECPHEC, and present papers and government strategy on tobacco control.

For example, RECPHEC organized a one‐day consultative meeting of the concerned ministries of His Majestyʹs Government to develop a consolidated and coordinated effort to respond to the FCTC, since tobacco control could not succeed with the effort

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of only the Ministry of Health. This workshop was the first of its kind in Nepal, where all the concerned Ministries including Environment, Agriculture, Health, Finance, and Law and Justice presented papers on the issue. The main objective of this workshop was to encourage the government to sign the Framework Convention on Tobacco Control (FCTC) and to strengthen the network of private agencies, government, civil society and media to implement the FCTC in Nepal.

RECPHEC also produced an Advocacy Kit for Members of Parliament. The kit contained information on different health issues including tobacco, allowing RECPHEC to integrate tobacco control advocacy into other important health issues.

Following years of advocacy efforts, Nepal experienced a great success when ProPublic, which works closely with RECPHEC, filed a case with the Supreme Court for implementation of tobacco control policies. On 15 June 2006, the Supreme Court made a landmark decision against tobacco. RECPHEC appealed to the government of Nepal to take immediate action to make the necessary arrangements in response to the Supreme Court decision.

RECPHEC consulted with the Legal Consultant of the Health Ministry on preparation of the Tobacco Control Act Draft legislation; the draft was later submitted to the Ministry. Finally, after years of discussion, the Government of Nepal ratified the FCTC in fall of 2006. Existing GO‐NGO collaboration will no doubt prove vital in efforts to implement the provisions of the treaty.

II. Capacity building

The traditional approach to tobacco control has been to educate people, often school children, about the harms of tobacco, and assume that such knowledge would be sufficient to result in behavior change. Unfortunately, international experience indicated that the extreme attractiveness and nearly universal presence of tobacco advertising, combined with the low cost and easy availability of tobacco products, and the ability to smoke just about anywhere, easily overrode the messages taught in schools. In addition, the tobacco industry has deliberately used the tendency of

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adolescents to rebel against adult authority to counter the effectiveness of such campaigns, themselves carrying out so‐called youth smoking prevention campaigns which actually encourage youth to smoke by portraying it as rebelliousness and self‐assertiveness.

What is successful in reducing tobacco use is a comprehensive set of policies, specifically a ban on all forms of advertising and promotion, higher taxes on tobacco products, smoke‐free public places, and strong pack warnings. Such measures can be complemented by measures to reduce smuggling, to inform the public about the importance of such policies, and to target difficult‐to‐reach populations which may not be directly affected by national policy.

In order to increase the effectiveness of the work of local organizations and government officials on tobacco control, it is important to share the international lessons learned of tobacco control, in terms of what works and what doesn’t, and how to achieve sustained reductions in tobacco use. Capacity building of key individuals to carry out effective work is thus a critical part of the work, always assuming that mechanisms are in place, or will be put in place, to allow those trained actually to put to use what they have learned.

Capacity building also has a significant extra benefit in being a method of recruiting new partners to the work+ and motivating them to become involved.

Lesson learned: Capacity building of key individuals can help expand the network and ensure that those working on tobacco control engage in efforts likely to be successful in achieving reduced rates of tobacco use.

Examples: India: Expanding the network

The HealthBridge program in India works actively on NGO and government capacity building throughout the country. Specific features of HealthBridge’s NGO training programs included the effort to address locally relevant topics such as poverty, agriculture, and marketing; involvement of local trainers in planning and in training; involving network members as speakers; ensuring that workshops were organized by well‐known local organizations; and utilizing a participatory rather

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than didactic design. Among other subjects, workshops always addressed the development of a Plan of Action, and linkages to additional resources.

Significant outcomes of training included an increase in local and national action, and the existence of more watchdogs to monitor implementation of the national law.

In addition, the India program extended beyond its borders, as the Program Director also worked to share lessons learned and build the capacity of organizations and governments in various countries in South Asia.

Bangladesh: ensuring nationwide capacity for tobacco control

WBB Trust, in partnership with the Bangladesh Anti‐Tobacco Alliance, has organized two national workshops and several local workshops to train NGO staff on tobacco control issues. The second workshop focused specifically on law implementation, following passage of a comprehensive tobacco control law. In addition to building capacity of local staff, the workshops were successful at identifying key partners for the work, thereby enabling law monitoring and implementation efforts to be truly nationwide.

Vietnam: Capacity building of government partners

Capacity building in HealthBridge’s program in Vietnam targeted two groups: 1) hospital managers, in order to build knowledge and skill on implementing and enforcing smoke‐free policies in hospitals; and 2) the Health Trade Union (HTU) and officers of the Department of Therapy of the Ministry of Health on how to manage and follow up implementation of smoke‐free policies in hospitals. In addition to the objectives established at the beginning of the program, government teamwork and skill in project monitoring were improved.

In the case of hospital managers, HealthBridge provided technical support to workshops (speakers, facilitator handouts and IEC materials). HealthBridge staff collected best practices in development of smoke‐free hospitals from the Internet and available literature, and then drafted guidelines for development and criteria of smoke‐free hospitals, which they printed as a manual and disseminated in the workshops. In most cases, HTU monitored project activities, integrating the monitoring into their regular hospital visits.

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For the second target group, capacity building was achieved through the strategy of “learning by doing”. HTU was involved in all stages of project implementation, including material development. The Department of Therapy also shared the criteria they had developed for smoke‐free hospitals with the program team for comment; that is, government actively solicited NGO input into its program.

HealthBridge discussed with HTU who would most benefit from and be able to use what they learned in the training: those who have influence on hospital policy development and implementation. This collaborative process resulted in trainees being either the member of the Board of Directors, President or Vice President of the Hospital Trade Union or Head Office of Medical Affairs for the hospital—people responsible for implementing hospital regulations and for quality of care.

The training agenda included the effects of smoking (active and passive), the criteria of a smoke‐free hospital, and steps for making hospitals smoke‐free. One innovative technique used in the workshops was to identify, in the course of discussions, hospitals with good experience in implementing the Minister’s Circular on smoke‐free hospitals, and then invite them to be speakers at the next workshop. This tactic proved extremely valuable, as it encouraged the participants in their own efforts, helping them to see the project targets as both realistic and achievable.

The program was also fortunate in that HealthBridge’s tobacco control program manager had several years of experience working in a government hospital. Her experience helped to answer several questions about solving the problems and overcoming the barriers while working on the program, which further helped in creating confidence and belief in its success. The value of utilizing local experience should not be understated; while international consultants may provide useful insights and ideas, people often respond most positively to those closer to home, whose experiences seem more relevant and thus replicable.

III. Media

Media is a key partner to get messages out to a larger audience and attract government attention. Newspapers, radio, and TV can all be used to communicate both with a general audience and with policymakers, often at very little expense. Partners in the South‐to‐South (S2S) network quickly became media experts, or further enhanced existing expertise. In addition, partners utilized their media skills

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to strengthen other health and environment programs. Success at gaining media attention occurred despite the large tobacco company advertising budgets, indicating that it is possible, through a variety of creative means, to overcome tobacco industry domination of both electronic and print media.

Lesson learned: Failure to gain positive media attention is likely to be due to insufficient creativity, messages that are not sufficiently interesting, or to the tendency to repeat the same information (for instance, always about health) rather than make the tobacco control issue appealing. Journalists and editors often prefer controversial messages or ones addressing issues of politics and economics. By studying media and trying different ways to access it, it is possible to achieve success despite the tobacco companies’ large budgets; such success can also spread to other fields of work.

Examples: HealthBridge published a joint media/research guide, combining two previous guides on low‐cost work with media and on research for advocacy. While the previous guides had focused exclusively on tobacco control, the revised version incorporated lessons from other programs, particularly car control and promotion of fuel‐free transport, gender, human rights, and the environment. HealthBridge has learned many lessons in its advocacy work, and those lessons can usefully be applied in other countries. Given that many people working internationally are not native English speakers, HealthBridge attempts to use plain, simple language while offering colorful illustrations from throughout the world of low‐budget, successful activities.

REDEH in Brazil conducted press conferences inside the national Congress, disseminating a list of senators who were “against” public health. REDEH first contacted 81 senators to see if they were for or against ratification of the FCTC. When only 24 replied that they supported ratification, REDEH decided to turn the whole idea upside down by issuing a press release, saying that Brazil had only 24 senators committed to public health. This gained tremendous media attention, and helped turn the whole situation around. In addition, REDEH had actors dress up in costumes and act out a skit of the seductive cigarette lady, Ms. Nicotine, chaining a helpless lung

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inside the Congress. Such colorful and creative ideas proved essential to gaining media attention and support.

As with all the other partners in the network, SOS Tabagisme‐Niger has maintained a close relationship with media. This relationship was perhaps facilitated by the fact that the president of the NGO, Inoussa Saouna, is himself a former radio journalist who was fired due to his outspoken stance against the activities of the tobacco transnationals. M. Saouna has from the start been active in recruiting journalists to join in his tobacco control network, so that reporters and those working on diverse issues such as consumer protection, environment, human rights and HIV/AIDS work closely together. This close relationship has helped ensure the success of their advocacy efforts, which finally resulted in Niger’s ratification of the FCTC and passage of a tobacco control bill.

In Bangladesh, WBB Trust used its strong media network to begin working on another important health, environmental, and economic issue: transport and urban planning. Media responded with great skepticism at first, indicating that while they tended to trust WBB given its strong reputation on tobacco, what WBB was saying about transport was completely counter to everything the journalists had ever heard. However, with time to consider the issues and the evidence, journalists quickly came on board, and WBB witnessed an enormous surge of support by journalists in record time. The tremendous investments made in developing its media network thus became of immediate use in addressing other important issues.

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India: Taking action against illegal advertising

Indian activists noticed that a cityʹs new and trendy daily, DNA Sports, was regularly promoting the multinational tobacco brands Marlboro and Mild Seven under the guise of covering Formula One races. The activists wrote to the newspaper, drawing its attention to the fact that such coverage violated the national law, which bans promoting tobacco logos, and noted in their letters that evidence from India and abroad confirmed that exposure to tobacco sports sponsorship increased childrenʹs experimentation with and uptake of the tobacco habit.

Activists waited for one month, but received no response to their correspondence. Nevertheless, they continued monitoring the paper for further violations. Imagine their surprise when they saw that coverage of Formula One in the daily in the weeks following the letters including the masking or erasing of cigarette brand names! This suggested that simply by alerting offenders of their violations of national law, they may voluntarily choose to comply.

Media advocacy in Nepal

RECPHEC has worked actively to form a strong media network for tobacco control work. Specifically, RECPHEC helped a group of media representatives committed to working on anti‐tobacco campaigns to form a group called “Media Object”. The objectives of the group are to raise awareness on tobacco and health, publish articles in different newspaper and magazines, and to publish analytical articles and reports on tobacco promotion and marketing. In addition, Media Object, with the support of RECPHEC, conducted a study on Smoking and Tobacco Use in Nepal.

Another active media group in Nepal committed to working on tobacco control is the Health Journalists Association of Nepal (HEJAN). HEJAN is also a member of the Tobacco Control Network of Nepal.

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Recognizing the importance of media for achieving government policy change, RECPHEC has consistently worked closely with different media bodies. For example, RECPHEC organized a press briefing to inform people that the FCTC was coming into effect globally and to urge the Nepalese government to ratify the treaty as early as possible. As part of the press briefing, the Executive Director of RECPHEC, Mr. Shanta Lall Mulmi, gave a TV interview on “the FCTC and Nepal”, which was telecast in the prime news bulletin.

RECPHEC also succeeded in convincing the Ministry of Health to begin awarding journalists annually for their contribution to anti‐tobacco campaigns. RECPHEC also gains much media coverage through its extensive district network:

Chitwan television telecast the street drama organized by the network group of Chitwan on the occasion of World No Tobacco Day.

Local FM of Banke broadcast a program on how the Muslim community is against tobacco products. The Muslim community has agreed to make all Madrassa (religious schools) smoke‐free zones.

Two FM stations broadcast interviews with Mr. Shanta Lall Mulmi on the district network and its activities on tobacco control.

Image TV telecasted a special interview with Mr. Shanta Lall Mulmi on FCTC ratification.

In addition to district‐level media coverage, Nepal Television 2 telecast a special thirty‐minute program on RECPHEC’s activities during primetime (7:30 pm) on 9 September 2006; the program included an interview with the Thamel Tourism Board on a car control campaign conducted with RECPHEC, and field campaigns on tobacco control. RECPHEC has also published articles, comments and news in national daily newspapers of Nepal. RECPHEC collects press clippings of tobacco‐related news and articles from different national newspapers.

Nigeria: Innovative use of the media

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Environmental Rights Action (ERA) in Nigeria has been tremendously successful in generating media coverage of tobacco control issues. The success is particularly remarkable in that the media has a long history in Nigeria of being friendly to the tobacco industry, obligingly publishing their press releases while ignoring any opposing viewpoints. In fact, Nigeria serves as proof that lack of media coverage is far more likely to be due to inadequacies on the part of media programs than to media bias. That is, while many media houses around the world are friendly to the industry, in any country normally some will respond to news on tobacco control; what they will not necessarily publish are uninteresting articles about how tobacco harms health. By becoming experts at media advocacy, people can usually overcome the industry‐sponsored opposition of media to tobacco control coverage, and ERA has been enormously successful at doing just that.

In the course of their media advocacy, ERA staff members have identified various (tongue‐in‐cheek but serious) key approaches:

Always stay on top of tobacco control issues, with plenty of up‐to‐date information. Journalists like credible and respected sources of news.

The media has a flirtatious side, and will never say yes at the first approach. Consistency and resilience are key, or in the words of the old saying, “If at first you don’t succeed, try and try again” (but also examine your approach to see whether you could do something better the next time!).

Media packs, with high quality, interesting, and well‐presented information, are an indispensable tool for media campaigns.

Journalists are often willing to attend training workshops and roundtables to broaden their knowledge about tobacco control; some journalists will even become devoted to the issue of tobacco control and pursue the issue on their own following the training.

It can be helpful to identify and select specific journalists and media houses as targets; in other words, one can develop strong relationships with a limited number of journalists while continuing to send information to a broader range; the closer personal relationships with a limited number of journalists will typically account for most of your coverage.

Make tobacco control attractive to journalists by linking tobacco with corruption, poverty, development, trade, the Millennium Development Goals (MDGs), and the country’s Poverty Reduction Strategy Paper (PRSP).

Create news through rallies, petitions, and so on. That is, activities can be designed specifically to generate news.

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Arrange trips for journalists around issues such as the plight of tobacco farmers; one such trip proved extremely helpful in Nigeria for generating media coverage.

Visit media houses periodically to socialize with journalists; after all, journalists are people too, and appreciate a personal touch.

Show interest in journalists’ careers by sending them information not only on tobacco control, but also on fellowship or training opportunities, and on other, non‐tobacco news.

Organize an end‐of‐the‐year dinner, with a theme such as appreciation of all their support to tobacco control, or how “we are a family”.

Like other people, journalists love free things: pens, caps, t‐shirts, diaries and calendars. There is of course a big difference between small fun gifts and actual bribes!

Nigeria’s media campaign generated many successes, including:


Success in attracting policy makersʹ attention: Nigeria signed and ratified the FCTC.

Achievement of a partial restriction of advertisement as a panicky measure from the Advertising Practitioners Council of Nigeria.

Direct responses from BAT following a trip organized by ERA for journalists to visit poverty among tobacco farmers.

A probe of BAT by the House of Representatives following one of the trips to the farmers and the media campaign around it.

Vietnam: Strengthening a media network for law enforcement

Health Bridge’s Vietnam tobacco control program has been fortunate in attaining synergy among a number of different projects, where each project is able to strengthen the others. Funding from the Rockefeller Foundation allowed HealthBridge to hire a media officer who could then develop and maintain a media

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network. The media network meant that HealthBridge could develop close relationships with reporters of various important newspapers, who grew increasingly willing to write about tobacco control. In addition, the media officer regularly monitored media coverage for positive and negative coverage of tobacco control and for any evidence of violations of tobacco control law. In the case of violations, the media officer immediately alerted the government body for tobacco control, VINACOSH, and other responsible authorities.

HealthBridge also utilized the opportunity to gain funding from Research for International Tobacco Control (RITC) in Canada, to conduct a survey with editors and reporters of newspapers to identify gaps in their awareness, attitudes, and perceptions of problems caused by smoking, tobacco control policy, and the FCTC. With the support of another small grant from the International Union for the Control of Cancer (UICC), HealthBridge developed and conducted two training workshops with journalists to address those gaps.

The media has played an active role in supporting the HealthBridge program for smoke‐free hospitals, frequently responding positively to information sent by the HealthBridge media officer on the baseline survey and project activities. In addition to print coverage, HealthBridge has also worked with Vietnam TV to develop a report on the harmful effects of passive smoking. HealthBridge also developed a TV spot educating smokers not to smoke in public places including hospitals.

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Media can be used to serve many purposes, as the Vietnam program demonstrated. In order to promote the concept of smoke‐free hospitals, HealthBridge provided media with information on the project, including the success and challenges; media in turn disseminated the project information to the public. Without the use of media, it would not have been possible for HealthBridge to reach such large audiences with information about the importance of smoke‐free hospitals and the need to comply with government regulations making hospitals smoke‐free, as well as messages about not smoking at home in the vicinity of others.

IV. Law enforcement As important as laws are for tobacco control, laws are of little use if they are not properly enforced. France is an example of a country with a strong law banning smoking in public places that may do more harm than good, as the law is widely ignored. This may encourage people to disregard laws in general, and to not respect any future attempts at making places smoke‐free. Widespread flouting of laws also gives lawmakers the impression that laws are of little use and need not be developed in other areas. It is thus important, not only for tobacco control but also for other sectors, to ensure both the passage of legislation and its effective implementation.

Governments have many responsibilities, and can only afford limited effort in the field of tobacco control. Law enforcement is just one of many areas in which GO‐NGO partnerships are critical for success. The roles NGOs can play in law enforcement include:

Monitoring of law violations, including making a list with full details of places where tobacco is advertised, collecting packets that do not carry the proper warnings and noting the place of sale, and observing compliance with bans on smoking in public places, again making notes of the place and time of observation. Such information can then be given to government officials in charge of law enforcement, along with a copy of the law if needed.

Follow‐up with police and appropriate government officials on actions taken in terms of law violations.

If those measures do not prove successful, work with media to highlight gaps in law enforcement and thus put pressure on authorized officials to follow through with their responsibilities.

Lesson learned: NGOs should not assume that governments can bear full responsibility for law enforcement. Where enforcement is lacking, rather than simply criticize, NGOs should assist governments in strengthening enforcement.

Examples: The HealthBridge program in Vietnam actively monitors media for any evidence of law violation, which it then reports to the government

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authorities. Active communication between NGOs and government ensures follow‐up on violations.

In Bangladesh, WBB Trust works closely with NGOs and local officials throughout the country to ensure proper monitoring and implementation of law. Specific examples include training network members on the contents of law, how they can engage in monitoring, and to whom they should send the information about violations (always ensuring that a copy comes to WBB, which WBB then forwards to national government); directly advising authorities throughout the country on their responsibilities for enforcement; helping to arrange mobile courts to address violations directly where they occur (for instance, by taking down signboards); reminding government officials to publish a notice in newspapers about the starting date for new warnings on cigarette packs; and working with media to maintain awareness of the content of the law and the importance of compliance.

V. Targeted research

Policymakers may avoid taking any serious action on tobacco control due to concerns, legitimate or otherwise, that tobacco control will somehow harm the economy, cause an increase in smuggling or a loss in jobs, or prove ineffective at improving public health. When such arguments are clearly a barrier to action, it may be necessary to conduct quick, focused, low‐cost research for advocacy to challenge such arguments.

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While high quality research is often necessary, in other cases, particularly where advocacy is concerned, time is essential. Funds are often limited. In addition, where concerns are symbolic rather than legitimate, the need is not necessarily for information that will change people’s minds, but rather for a convincing document that will challenge false arguments. Sometimes all that is needed is an opinion poll, or a collection of case studies on how people have thrived since shifting their livelihood from tobacco to other sources of income. Since even the most expensive, lengthy, careful research has flaws that can be challenged, it is not necessarily justifiable to engage in lengthy, expensive research in the hopes that it will be taken more seriously than something done more quickly.

Lesson learned: Where appropriate, targeted research meant to respond to a specific argument against tobacco control, or a specific concern, or to highlight the need for action, can be invaluable in promoting the cause.

Examples: Niger: Researching the impact of tobacco use on poverty and employment

SOS Tabagisme‐Niger conducted two research projects to further its advocacy goals, one on how tobacco use further increases poverty, and one on the exceedingly limited benefits of employment related to tobacco. Publication and distribution of the reports proved critical in gaining new allies to the cause, demonstrating the importance of tobacco control in poverty‐struck Niger, and advancing the political agenda for ratification of the FCTC and passage of a tobacco control law. The reports also helped to counter objections by the tobacco industry that the industry was economically important for the country. Activists finally had the information in their hands to demonstrate exactly the opposite, that is, that the tobacco industry, while enriching certain individuals, can contribute to impoverishing a nation.

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Action research in Nepal: Collaborating with Tribhuvan University

RECPHEC in Nepal demonstrated how an NGO with limited experience in research could effectively conduct quality research to contribute to its advocacy campaigns. RECPHEC partnered with Padma Kanya Campus of Tribhuvan University on several research programs. A total of eight field studies were conducted by university students of the Womenʹs Studies Program on different dimensions of tobacco. The research studies covered a range of issues, including prevalence of tobacco use, tobacco consumption by women and its impact on their reproductive health, their children’s birth weight, and infant mortality; the impact of media on tobacco use, economic and social impact of smoking, and perception of girls towards tobacco use.

The research program, in addition to providing important information for RECPHEC’s advocacy campaign, had the added advantage of helping to train young women to conduct research. Partnering with a university was in fact an innovative and cost‐effective way of addressing the need to conduct quality research while lacking sufficient funds and expertise to do so.

Bangladesh: Tobacco taxes and the poor

HealthBridge and WBB Trust provided extensive technical assistance to a Bangladesh Anti‐Tobacco Alliance (BATA) member organization, Manobik, to develop a proposal and carry out a research project on the likely effects on the poor of raising tobacco taxes. Manobik’s proposal was funded by the Government of Bangladesh. In addition to providing important funds, this also meant that the research results were more likely to be used by the government than if the funding had come from elsewhere. (Manobik had previously, successfully, lobbied the government to include tobacco control issues in its list of programs for which it provides research funding.)

The research included a survey of 1,000 low‐income tobacco users, both male and female, and individual interviews and focus group discussions with the poor (tobacco users and non‐users) and with members of civil society (professors, government officials, NGO workers, etc.). The questions included whether people considered that it was more important to keep taxes low on tobacco or on other products; how low‐income tobacco users would be likely to respond to a tax

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increase; whether tobacco users would like to see their children take up smoking; and whether the poor could be helped in a more useful way than through subsidizing tobacco by maintaining low taxes. The research yielded extremely useful information, as well as revealing great support for increases in tobacco taxes.

Vietnam: Research for policy and evaluation

In order to evaluate the effectiveness of its program for smoke‐free health facilities, HealthBridge in Vietnam conducted both a baseline and a post‐intervention survey on a sample of hospitals to investigate the level of implementation of smoke‐free policies. In addition to information regarding attitudes and knowledge of medical professionals, patients and public about second‐hand smoke, the survey collected information on level of implementation of and compliance with smoking bans, as well as barriers and suggested measures to overcome them.

HealthBridge Vietnam has also contributed to international understanding of the relationship between tobacco and poverty through a research program supported in part by RITC and further supplemented by the Rockefeller Foundation. By adding a few questions on tobacco use to a much larger survey on children’s well‐being, HealthBridge was able, at relatively little expense, to obtain an enormous database of information showing the differences in expenditure on education and food of tobacco using and non‐using families.

In Vietnam as elsewhere, the tobacco industry argues that it makes a significant contribution to the country’s economy. This misleading information needs to be weighed against the health costs of smoking, and such information needs to be included in measures for policy advocacy and public education. To serve this purpose, HealthBridge in Vietnam worked with RITC to organize a workshop to review studies on the health costs of smoking in the world and to investigate the possibility of conducting a similar study in Vietnam. The workshop involved policymakers (VINACOSH), tobacco control specialists, advocates and international and local researchers. The workshop came to the conclusion that a very good research program could be conducted in Vietnam, and possibilities are now being pursued for conducting such research.

HealthBridge also conducted research to investigate the effectiveness of current health warnings, and technically and financially supported the Vietnam Association

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of Standards and Consumer Protection to conduct a public opinion poll to investigate the effect of and public support for graphic health warnings versus text warnings. The research findings were of great use in advocating for stronger, pictorial warnings on cigarette packs.

VI. Decentralization of work Tobacco control organizations tend to be based in the capital or other large cities. Such centrally‐based organizations generally have difficulties extending their programs throughout the country without forming partnerships with other local NGOs based in other areas. For any activity, be it promotion of law, building of public support for policy, or implementation of law, large portions of the country may be neglected if strong national networks do not exist to support decentralization of the work. One key aspect of tobacco control work is therefore the creation and maintenance of a national network. S2S partner countries put much effort into just such activities.

Lesson learned: In order to work effectively throughout a country, NGOs should look at building the capacity of smaller NGOs based in locales far from the capital, and at ensuring strong networking among NGOs throughout the country.

Examples:

In Nigeria and India, efforts were made to include in the national coalition members from other parts of the country. In Bangladesh, active communication with and support to a network of over 500 NGOs throughout the country ensured effective decentralization of work.

Decentralization of tobacco control work in Vietnam occurred partly through partnership with the Vietnam Public Health Association (VPHA), which has branches throughout the country. Through close collaboration with HealthBridge, VPHA was able to develop its capacity in tobacco control and deliver its experience to the district level via its provincial branches. Thus by working with VPHA, HealthBridge’s tobacco control program was able to reach to the grassroots level.

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Linking with other NGOs in Nepal

In Nepal, as in most S2S partner countries, networks operate at different levels, encompassing NGOs in other countries, those based in the capital city, and those scattered throughout the country. Nepal’s Tobacco Control Network has been actively involved since 2002 in advocacy and campaigning against tobacco use. The members represent a wide range of organizations and interests, consisting of Mrigendra Medical Trust, National Front Against Tobacco, Nepal Cancer Relief Society, Nepal Consumer Forum, Child Worker in Nepal, Nepal Heart Foundation, Pro Public, Health Journalists Association of Nepal (HEJAN) and Resource Centre for Primary Health Care (RECPHEC). The network initiated various programs both collectively and individually. The success of many of those programs resulted in substantial changes at planning and policy levels. For example, the national‐level advocacy campaign led by RECPHEC in June 1998 forced the government to ban advertising tobacco products in electronic media.

Following on its initial policy successes, in October 2003, the network drafted and submitted a draft Tobacco Control Act to the Ministry of Health. It also submitted a memorandum to the then‐Prime Minister demanding immediate ratification of the WHO’s Framework Convention on Tobacco Control (FCTC).

Mr. Shanta Lall Mulmi, President of RECPHEC, coordinated the Tobacco Control Network from 2002 to 2006. On 31st March 2006, representatives of 13 leading organizations met in RECPHEC’s office and decided to form a National Pressure Group Against Tobacco, Nepal. The meeting decided that the group would be led by a convener, who would change every three months to ensure active participation of all members.

Like other coalitions, the National Pressure Group Against Tobacco faced difficult questions about conditions for introducing new members, and for finding direction in the work that would keep the coalition together. In some cases, member organizations can never decide on rules for allowing new organizations to join, and their unwillingness to expand may cause some of the life to go out of the coalition. In the case of Nepal, member organizations decided to involve other groups through a selection process that would look at the work experience of applicant organizations in tobacco‐related fields. In order to do so, RECPHEC organized a planning process through which the member organizations presented their organizational profile and their work on tobacco‐related activities.

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In addition to considering the profile of would‐be members, participants in the meeting also discussed what the national pressure group would do after the Government of Nepal ratified the FCTC. The group decided to translate the text of the treaty into Nepali so that rural people would be able to understand the FCTC. The group also decided to begin work on passage of anti‐tobacco legislation. Since its formation, the National Pressure Group Against Tobacco, Nepal has also carried out various programs to encourage the government to ratify the FCTC. The network regularly updates and disseminates information on initiatives around the world with regards to the FCTC, passing on that information to both national‐level advocacy organizations and district‐level network committees on a regular basis.

Meanwhile, the tobacco control movement in Nepal achieved a significant victory when, on 14 June 2006, in response to a case filed by network member Pro‐Public, the Supreme Court issued a strong judgment against public smoking and tobacco advertising. The Supreme Court asked the government to impose a ban on smoking in all public places, initiate action to ban tobacco advertisement in the print media, raise public awareness against tobacco through the mass media, and to enact necessary and comprehensive anti‐tobacco legislation.

Highlights of network activities in Nepal include:

Joint organization of a press meet program. Journalists from different media group and members of national pressure group participated in this program.

Delivery of a letter to the Kathmandu Municipality Acting Chief to remove all the tobacco related billboards in the municipality areas and replace them with anti‐tobacco boards.

Presentation of a signed declaration letter to the Secretary of the Ministry of Health and Population and to the Deputy Prime Minister and Health Minister, urging the immediate ratification of the FCTC.

Placement of anti‐tobacco billboards at six different intersections in Kathamandu Valley.

Lobbying in Parliament for the ratification of the FCTC.

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District level activities

In view of the very unstable political system and considering that the FCTC ratification process would be delayed due to the absence of a legitimate government, RECPHEC decided to build pressure at the community and district levels by organizing a series of interactive programs on the FCTC. The purpose of these programs was to sensitize community‐based NGOs about the FCTC and Smoking Prohibition Act‐2057. Participants included NGOs, medical teachers, doctors, nurses, and activists, including those campaigning for women’s rights. A workshop in Pokhara led to the decision by the participating organizations to work collectively as a District Level Tobacco Control Network.

In part due to that success, as well as based on the positive feedback from other district‐level workshops, RECPHEC decided to form district network groups. Strong and effective advocacy groups at the district level help to maintain public pressure at the grassroots level; districts can also contribute to national campaigns, for instance for ratification of the FCTC. Thus, RECPHEC established networks in 13 districts for advocacy work on the FCTC. A total of 365 NGOs (184 member NGOs and 181 affiliated NGOs) in 13 districts have joined in this anti‐tobacco movement.

In view of the overwhelming response and the quantity of awareness and advocacy campaigns organized by the NGO network members utilizing their own resources, RECPHEC decided in 2006 to extend its activities to twelve more districts of Nepal. Activities carried out at the district level include integrating tobacco control issues into other activities at the community level including in non‐formal education; advocating the local government to take policy measures; encouraging GOs, NGOs, and individuals to create and maintain tobacco‐free zones; distribution of posters, pamphlets, and stickers; mounting anti‐tobacco signboards; conducting signature campaigns, and submitting of a memorandum to the Chief District Officer for the ratification of the FCTC.

VII. Managing a network

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Difficult as it is for different agencies and individuals to work together, such collaboration makes the work far easier and more effective. Creating a network is perhaps the easiest step; ensuring that the network’s members work together in a mutually‐supportive, or at least not hostile, environment is perhaps the most difficult part. S2S members learned many lessons over the course of the program in managing networks, and in particular on managing the personalities of network members!

Some strategies used by different members include:

Creating sub‐committees within the network or alliance so that many people can assume an official post.

Rotating at least symbolic leadership positions, such as chairing of meetings, so that all members feel they have a role and a stake in the alliance.

Taking the time to meet individually with members who are either the victims or source of problems, to attempt to address the issues and resolve them peaceably, or ensure active participation by others outside the network.

Lesson learned: A key technical skill often neglected in tobacco control and other development work is the management of different personalities in order to achieve successful collaboration. Management of networks involves many skills, which must be learned in order to ensure effective cooperation and a genuinely national program.

Examples: Bangladesh: Success through successful networking

WBB Trust has achieved significant success over the past several years. Such success would not have been possible without the active cooperation of NGOs working in a variety of sectors. As co‐founder of and Secretariat for the Bangladesh Anti‐Tobacco Alliance, WBB has found a range of methods necessary to keep its network strong and active, similar to its approach to maintaining a strong relationship with government. Such methods include:

Providing a variety of services to member organizations, such as office space in WBB for volunteers, training to volunteers, support with media activities, and assistance in writing grants and carrying out projects.

Printing stickers with the names of local NGOs, to help local NGOs publicize their organization while also spreading messages about tobacco control.

Providing direct input in terms of suggestions of working methods and support in carrying out advocacy‐related activities.

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Regular communication by phone, letter, e‐mail, and in meetings, to ensure that members feel genuinely part of the network, and to facilitate cooperation.

Vietnam: Active collaboration among GOs, NGOs, and international agencies

HealthBridge and the WHO in Vietnam jointly established the Tobacco Control Working Group (TCWG) to ensure ongoing communication about and collaboration on tobacco control issues. The network includes over twenty organizations consisting of UN agencies, the WHO, NGOs and government organizations that are active and interested in tobacco control. The agencies regularly meet to exchange information and discuss issues and solutions in tobacco control.

Progress, problems, and other experiences in tobacco control, as well as research findings, shared in regular meetings of the TCWG help to encourage NGOs to stay active in tobacco control. The information also contributes to improving the knowledge and experience of the members.

Many members of the TCWG have developed small projects and received technical and financial support from HealthBridge to implement them, including “Smoke‐free university” implemented by the Hanoi School of Public Health; “Developing smoke‐free communities” by the Vietnam Elderly Association; “Telephone quit counseling” by a local NGO; and “Developing smoke‐free areas in restaurants” by the Business Service Society. In addition to advancing tobacco control, the capacity of partners has improved during the implementation of their projects.

While working closely with the Vietnam Public Health Association (VPHA) to implement many important tobacco control projects, the role and independence of VPHA were promoted. The role of coordinating and hosting TCWG meetings was handed over to VPHA. The VPHA was encouraged and helped to develop tobacco control programs at both central and provincial levels. While the technical inputs from HealthBridge helped ensured that the program was in line with the national agenda and utilized best practice in tobacco control, the objectives and activities were decided and planned by the partners to make sure that they were appropriate to local needs and local capacity.

HealthBridge also introduced VPHA officers and researchers to the international tobacco control community and helped them to access capacity building opportunities in tobacco control through GLOBALink and the South East Asian Tobacco Control Alliance (SEATCA). HealthBridge also helped ensure that VPHA was involved in high‐level discussions of national tobacco control issues. This approach helped VPHA to extend its influence and credibility in tobacco control as well as to develop its capacity.

What is particularly important and different about the Vietnam experience is its success in including both government and international agencies in close and direct collaboration with NGOs. In most countries, such working groups, alliances, or

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coalitions are generally limited to NGOs. The success of the initiative is due in part to many years’ experience of close collaboration across different sectors; with long‐established working relationships, it was possible to formalize the relationships into a working group, which in turn greatly enhances the effectiveness of the work and potential for collaboration of all the partners involved.

India: Successfully managing a network in a country of enormous size

Both relatively smaller countries and those with a strong focus in one city (usually the capital) often find it much easier to maintain an active coalition than those like Nigeria and India which have important cities spread over an enormous geographic distance. Both countries have faced tremendous challenges in figuring out how to maintain an active coalition while rarely able to bring most members physically together. The other option, of excluding large and important portions of the country, is of course as unacceptable as trying to spend the money on flying activists in for regular meetings.

India faced additional challenges, in that many groups had a long history of involvement in tobacco control, and thus felt that they were uniquely positioned to offer guidance and leadership within a coalition. Where talent and experience are spread across many groups and individuals who are reluctant to accept a less prominent role, organizing a coalition is usually a doomed project. In fact, several earlier attempts at organizing a coalition in India failed, until the active intervention of the Advocacy Institute of the United States helped support the development of the current coalition.

Given the size and complexity of the country, a two‐pronged membership recruitment strategy was important for the Indian coalition. At the national level, members are recruited through national conferences and annual meetings. At the local level, coalition members identify states with few activities in tobacco control, and then build capacity of potential NGOs, bringing them into the main coalition.

In order to distract members from territorial battles or disputes over positions within the alliance, various strategies were identified and carried out:

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Identifying a workable and common macro‐level goal: national law;

Arranging media interviews, and press conferences and inviting members to speak, so that members can both share their knowledge and gain desired recognition without having to be involved in the hard work of organization;

Creating “Swiss Cheese” press releases, which include basic information while allowing different organizations to fill in the holes with their organizational name and other desired information; while written by one person (the HealthBridge Program Director in India), the organization filling in the holes gets the publicity;

Co‐organizing workshops, often involving a good deal of groundwork by the HealthBridge Program Director while most recognition goes to the other organizing agency; such collaboration, while avoiding taking the credit, often is vital to alliances;

Co‐organizing activities which involve many responsibilities that can be divided among different participants, such as national conferences.

Experience in India pointed out other lessons as well. For instance, it is of great importance to divide up tasks among different members. Having too much or too little work can discourage partners. There may be individuals who are eager to participate but lack skills; for them, participation with mentoring assistance can mean an invaluable acquisition of skills, which will both assist them in future work and possibly increase their support for the coalition which gave them such an opportunity. For those who are extremely busy but yield a powerful position, and whose name can be an important asset, honorary or symbolic positions (such as serving on an advisory committee) may prove the most useful, allowing such people to make a contribution without requiring an impossible expenditure of time. Finally, there will always be those who put in far more time and effort than others; expressing appreciation (even if it is to yourself!) is important, as is remembering that a certain level of sacrifice is normally necessary to maintain an active and healthy coalition.

By generating new issues and activities, it is possible to maintain interest and involvement among network members. That is, when signs of interest lag, it may be the time to consider new campaigns or other activities, which will give organizations a chance to feel useful and gain active involvement. Coalitions need not be defined simply as groups that meet on a regular basis; when members address various issues, whether or not they attend meetings, they are making an important contribution. The activities themselves also form the basis for involvement for many organizations which might otherwise drop out.

Welcoming new members, ideas and resources helps keep coalitions active. If it is administratively difficult to create a process by which new organizations can become formal members, consider other forms of membership, such as founding members,

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affiliate members, network members, etc., but be sure to allow new organizations the chance to join—while of course ensuring that they have no links to the tobacco industry. In the same way, new ideas should be welcomed and encouraged, and resources sought—be they financial, human, or other—to keep the coalition alive.

When welcoming new members, one may discover that some people’s creativity is greater than their understanding of tobacco control. Such a problem usually can be surmounted through accepting it as a challenge—that is, viewing it in terms of the need to build the capacity of new or existing members whose approach to tobacco control does not benefit from the wealth of international experience available. Coalition meetings can serve as capacity building opportunities, with different members giving short talks on various up‐and‐coming issues in tobacco control, or expounding on the key issues of the day, such as the contents of the FCTC or the reason why taxes should be raised and public education programs are of little effectiveness in reducing tobacco use. Newsletters can be used for the same purpose, as well as for highlighting the activities of different members, which then gives them further motivation for the work.

Cultivating shared leadership, though not easy, can be vital to long‐term success. If any one individual or organization attempts to control the coalition, and in doing so causes others to feel excluded, then some organizations may wish to leave. Individual leadership also limits the creativity and innovation of the coalition, as the activities may be shaped mainly by the ideas of a single person. Shared leadership helps resolve those problems, as well as encouraging both those in the shared leadership position and those who envision a future chance to assume one. Shared leadership can take many forms; to ensure stability, a single Secretariat may be important, and there may be only one person able and willing to juggle the various personalities of the coalition. But the active input of other members can continually be solicited, ensuring that the coalition represents the opinions of many.

Learning to delegate is a final important lesson. Not all tasks need be done by one individual or organization. If others are not capable, they can be taught. Like the proverb of teaching someone to fish rather than giving them fish, so building the capacity of other NGOs and individuals will ensure the sustainability of the coalition while easing one’s own workload. As opportunities avail, be sure to share them with other organizations, be they chances at a scholarship to attend a conference, to be a speaker in a press conference or seminar, or to apply for a grant application.

International networking

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So far this section has focused on the importance of countrywide networks and coalitions. But tobacco control work is also greatly advanced through international networks. Tobacco companies tend to carry out the same activities around the world, be they so‐called youth smoking prevention campaigns, “social responsibility” reports, or lobbying campaigns to avoid passage of strong tobacco control laws or increases in tobacco taxes. When activists explain how they addressed such issues in their country, that information is often of immediate use to activists facing the same problem in other countries.

In addition, international networking allows for greater sharing of information and ideas. International friendships can provide a support network and motivation for isolated activists lacking such support domestically, for example, people who are the only ones within their organization, or essentially the only ones in their country, working on tobacco control.

The South‐to‐South network itself was established not only to assist individual countries in their tobacco control policy efforts, but also to increase sharing across countries and regions. Activists gained much from the frequent e‐mail discussions of the Framework Convention Alliance (FCA); unfortunately, with the development of the FCTC, much of the active discussion on the FCA listserv ceased, and activists had to turn to their own individual networks for the reinforcement and support they had previously found from the FCA. All members of the South‐to‐South network expressed that the existence of a network is valuable to them, far beyond simply receiving funding for an in‐country program, and that they would prefer to remain part of a network than simply to receive independent funding.

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Ability to share lessons and experiences, to maintain networks, and to succeed in advocacy campaigns all depend to a great degree on interpersonal relations. The 13th World Conference on Tobacco or Health—pictured here—and other such meetings are a great opportunity for sharing and—perhaps equally important—help in building and maintaining friendships which are vital not only to the work, but to staying motivated and energized.

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The sensation of being part of a larger group, and the occasional face‐to‐face sharing at international venues (such as at international meetings for the FCTC, regional and world conferences, and S2S meetings), appeared to be the greatest strengths of the network. While a listserv was established for the network, it was not used as much as HealthBridge staff had hoped, perhaps partly due to the high work loads of individual members, which often makes communication seem more of a burden than a benefit. It may be easier and more comfortable for people to communicate one‐on‐one than through a listserv; certainly much of the communication among partners in the S2S program was on an individual basis rather than through the listserv, with individuals turning to each other for information or support. One key exception was the sharing of successes, which takes a gratifying form over a listserv, though congratulatory responses may be rare.

The face‐to‐face encounters were of great significance. Unfortunately, due to visa and other problems, it was sometimes difficult for HealthBridge to organize meetings in which all participants could attend. Despite this, a final meeting of the network at the close of the World Conference on Tobacco or Health in Washington, DC in July 2006 was hugely successful, and of particular note was the great friendliness among those attending. Despite having had few face‐to‐face encounters over the three years of working together in S2S, and despite limited communication by e‐mail, people were very friendly with each other, and the comfort level was

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high. Clearly, the psychological benefits of network membership were great despite limited communication.

One further difficulty with the S2S network bears stating; while the partners were mostly non‐native speakers of English, one in particular had extremely limited English, which inhibited direct contact with other members. The inclusion of Niger was only possible due to the fact that HealthBridge staff included French speakers who could communicate directly with the partner from Niger.

It was also interesting to note that language problems nearly disappear in direct interpersonal encounters; when a colleague from Niger shared a hotel room with people from other countries, they immediately became close friends, enjoying the challenge of conversing with very limited language.

Overall, it seemed the inclusion of a virtual non‐speaker of English, while making communication more difficult and increasing the burden in terms of needing to translate many group e‐mails into French, in no way reduced the effectiveness of the work, and the inclusion of a different culture and perspective benefited the network.

Finally, on the basis of equity and inclusion, it is hoped that networks would be sufficiently flexible to allow the inclusion of people of vastly different cultural and linguistic backgrounds, and that sufficient allowances will be made for those differences (such as by allowing the Niger partner to submit all his reports in French; this was greatly aided by the fact that it was possible to submit his portion of the reports to the Canadian government in French, while the rest of the report was in English; such a bilingual system is an excellent example of accommodating the multicultural nature of modern society). That is, accommodating diversity, while a challenge, should be viewed as an opportunity and benefit.

VIII. Public education

While international experience has made it clear that public education alone is of little or no use in reducing rates of tobacco use, it can be an important component of a larger tobacco control program which is mostly focused on law, taxation, and policy. Public education can be vital to gaining support for the passage of law and

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policy, the raising of taxes, and compliance with laws. Thus while relying on public education alone is a sure means to failure, ignoring it entirely can also cripple the effectiveness of an otherwise well‐planned tobacco control program.

Most of the partners in the South‐to‐South network engaged in public education largely indirectly, through the use of media. While media is an invaluable tool for reaching policymakers, it is also the most cost‐effective way to reach large audiences. For this reason, all of HealthBridge’s partners have used media to inform the public about the need for and importance of policies. Vietnam used newspaper and TV to draw people’s attention to the need to make hospitals smoke‐free. Bangladesh gained frequent TV and newspaper coverage of the need for passage of comprehensive laws, and organized many radio discussion programs on the issue. Niger actively engaged its media partners in raising the importance of tobacco control to the public as well as policymakers. India used celebrities to gain public support and interest, and the need for smoke‐free dining for cancer‐stricken children to further raise public attention to the issue of tobacco control. Brazil’s colorful approach to raising awareness of the need for tobacco control policy both gained public support and helped ensure the ratification of the FCTC. Nigeria’s many media campaigns, including highlighting the poverty of tobacco farmers, helped change public opinion away from unquestioning support of the tobacco industry.

In addition to media work, partner countries utilized many other methods to gain public attention and raise public awareness of tobacco control issues. A key theme has been that tobacco control should not just happen once a year, on WHO’s World No Tobacco Day (31 May). The colorful rallies and campaigns that occur on that day need to be repeated throughout the year, and S2S partners have been sure to do so, often through supporting other NGOs to carry out creative activities to attract public attention. WBB in Bangladesh used stickers as a way to reach people and gain the support of network members, in whose names the stickers are printed (receiving free merchandise works well with both NGOs and media personnel!).

Significantly, public education programs under S2S were always linked to campaigns to reduce tobacco use; that is, the problems were always accompanied by the desired solution. When people learned of the harms caused by tobacco use, their response tended to be, “If it is so dangerous, why does the government allow it to be freely sold and advertised?” By banning advertising, putting stronger warnings on packs, limiting the places where people can smoke, and raising taxes, governments sent a strong message that tobacco is as dangerous as health activists and doctors say. In turn, people were more willing to accept and support such policies when they understood the reasons underlying them. Policy and public education thus become mutually reinforcing.

Lesson learned: Public education can be an essential component of a comprehensive tobacco control program, ineffective though it is as a stand‐alone

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program. NGOs should work to create public support for tobacco control policies in order to ease their passage and enforcement.

Examples: Awareness raising and advocacy in Nepal: Reaching the masses

RECPHEC has been active in raising public consciousness and in motivating peopleʹs initiatives in tobacco control since 1997. At the field level, in Udayapur, Saptari and Gorkha, RECPHEC educates and gives information about tobacco to the women receiving Non‐Formal Education (NFE), to different womenʹs groups, Traditional Birth Attendants (TBAs), local youth, community people and GOs and NGOs. In other words, those attending non‐formal education receive information on different health issues including tobacco. RECPHEC feels that this type of education is very effective because women in turn educate or give information to family members and the community. The coverage from this type of educational program is significant: RECPHECʹs field program covers more then 60,000 people, particularly very low‐income groups and marginalized sections of the society.

RECPHEC has published information brochures, books, leaflets, quit cards, posters, stickers, pamphlets, booklets, and stickers on tobacco, and distributed those materials to its network groups.

Vietnam: Reducing the public acceptance of smoking

The Vietnam government faces extreme difficulty addressing the problem of secondhand smoke, due to the very high social acceptance of public smoking. Simply banning smoking in various areas would be of little or no use until public acceptance of smoking is addressed, unless enormous efforts in enforcement are possible. In order to support the Government of Vietnam in reaching its goal of reducing the social acceptability of smoking, HealthBridge partnered with the Vietnam Public Health Association (VPHA).

A mass media campaign was developed with the involvement of Vietnam TV, national radio (Voice of Vietnam) and three major local stations. It included seven TV spots to educate the public about the harmful effects of direct and passive smoking, and messages to encourage smokers and non‐smokers to change their

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behavior (that is, not smoke in the vicinity of others and to speak out against public smoking); and to promote smoke‐free public places. The TV spots were then aired on two national channels during prime time. The team also worked with Voice of Vietnam to develop radio spots, a “Q & A” series, and several other attractive radio programs. While radio is often neglected in media programs, it can be both an effective and low‐cost way to reach a large portion of the population. In the case of Vietnam, it was estimated that radio programs reached 25% of the population.

The HealthBridge ‐VPHA team is now working with two major newspapers to encourage women (who in most of Vietnam are mainly passive rather than active smokers) to speak out about maintaining a smoke‐free house. An additional campaign has been developed with a provincial public health association to work with children and women to promote smoke‐free houses in four provinces. Through the project, local TV, radio and the loudspeaker system (widely used throughout Vietnam by the government to give information to the public) will provide coverage, using the same messages developed by central TV and radio.

In order to develop the messages and to evaluate their effectiveness, HealthBridge and VPHA conducted both a baseline survey and a qualitative study. The research gathered information for message development and identification of appropriate channels for message dissemination. Both an international and a national expert in health communication were invited to work with the team to design the research and develop the messages. A small study was also conducted to test the appropriateness of the TV spots in the community before airing. A post‐intervention survey will be conducted to evaluate the effectiveness of the intervention.

Finally, as mentioned above, HealthBridge also developed a TV spot to promote smoke‐free public places, focused on hospitals. Other public outreach has occurred through newspaper articles, posters, leaflets, and a booklet.

IX. Managing difficult political situations

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However well one works out techniques for carrying out advocacy and other activities in the best of times, the context in which one works can sometimes force a radical change of course. During intense political upheavals, it may be impossible to work with government; it may even be difficult to leave the office! Political shutdowns have hampered the work in Bangladesh, Nepal, and Nigeria; Nepal even suffered from the lack of a legitimate government when the king seized power. In such situations, flexibility is key: flexibility in responding to opportunities in the political environment, in addressing obstacles due to political instability, and in fixing direction mid‐course when needed.

In Bangladesh, frequent hartals (opposition party strikes) make planning programs difficult, as they often must be postponed or canceled. In Nigeria, regular political difficulties and frequent power outages mean that activists required great adroitness in their planning. In Vietnam, as in many of the countries in which S2S works, the political system is “vulnerable” to corruption, which can give the tobacco industry an opportunity to influence policy through backdoor means. Vietnam addressed the issue through building an alliance with mass and professional organizations that shared relevant interests (that is, the Women’s Union, VPHA, and health professional association). A close relationship with media was also shown to be helpful in all the countries in limiting the ability of the tobacco industry to benefit from corruption, since bringing such activities to light made them difficult to sustain. Finally, in Vietnam as elsewhere, activists reported having learned how to use personal relationships to lobby for policies; that is, it is easier to make progress at higher levels with friendly relationships with some government officials.

Lesson learned: The best‐laid plans can go awry when political problems make planned work impossible. A flexible approach can help NGOs ride out such difficult periods, laying the groundwork through conducting in‐house work for which one otherwise has little time, or shifting attention to less political arenas while waiting for the situation to resolve.

Examples: Nepal: Tobacco control campaign during a conflict situation

Nepal experienced more than a decade of political conflict around the turn of the century. Due to the activities of both the Maoists and government security forces, development activists were not able to organize any advocacy campaigns at the district level. With the country undergoing such tremendous political difficulties, tobacco in fact became a non‐issue. Further, the previous government, whose leader owned a large share in the leading tobacco company, tried to discourage tobacco control campaigns in Nepal. Despite recommendations made by the concerned Ministries to ratify the FCTC, action could not be taken. During the King’s direct rule, not a single mass meeting or campaign was allowed at the district level until the mass movement of April 2006 succeeded in greatly reducing the King’s power.

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Working under such difficult circumstances meant a rethinking of the entire approach to tobacco control activities, consisting of a pragmatic decision to shift from national advocacy work to strengthening of the district networks, which would then be ready to take action once the political situation improved. During the politically unstable time, district organizations were able to sensitize people about tobacco control issues, include tobacco control as one of the cross‐cutting issues for public awareness, and convince local government officials to declare their office premises as a “tobacco free zone”. Those strong district networks will now be well‐placed to work for passage and implementation of a law to implement the provisions of the FCTC.

X. Publications for international use

It is easy to become so caught up in one’s own work that one forgets to share lessons learned with others, or to believe that one does not have important lessons to share. Language difficulties can also contribute to difficulties communicating and sharing ideas. Yet by sharing the methods and strategies used to combat the tobacco industry, one can greatly reduce the workload of colleagues around the world, and increase the effectiveness of the work.

Thus while such publications can require a great deal of work, in their preparation, printing, and dissemination, they are an essential aspect of sharing of experiences and advancing tobacco control goals.

Lesson learned: Efforts should be made to share strategies and working methods to increase chances of achieving positive policy change and appropriate implementation. Since many people working in tobacco control are not native speakers of English, such information should be written in simple, straightforward language, be clear and to the point, and where possible, be translated into other languages.

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HealthBridge produced a kit on tobacco and poverty in several languages, containing a CD, poster, postcards, and leaflet. Guides by HealthBridge on tobacco control over the past several years include (some of these have been translated into Bengali, French, Hindi, Portuguese, Spanish, and Vietnamese): • Using Media and Research for Advocacy: Low Cost Ways to Increase Success • Tobacco and Poverty, Observations from India and Bangladesh • Guide to Low-Cost Research for Advocacy • Using the Media for Tobacco Control • A Burning Issue: Tobacco Control and Development; A manual for non-

governmental organizations • PATH Canada Guide: Tobacco Control Law • British American Tobacco’s Youth Smoking Prevention Campaign: What are its

actual objectives? • Hungry for Tobacco: An analysis of the economic impact of tobacco on the poor

in Bangladesh

Articles:

• “Robbing the Poor”. WHO Lifeline, SEARO, Volume 1 Issue 2, April-June 04. • “Building Momentum for Tobacco Control: The Case of Bangladesh” in Tobacco

Control Policy: Strategies, Successes & Setbacks. World Bank and RITC 2003. • “Hungry for Tobacco: An analysis of the economic impact of tobacco on the

poor in Bangladesh.” Tobacco Control 2001;10:212-217.

XI. Importance of on‐going, long‐term funding In order to sustain a program, funding is critical. Unfortunately, the search for funding can often seem more important than the daily activities; after all, without money, all activities may grind to a halt. Thus tobacco control activists may find themselves spending far more time than they wish searching for short‐term projects to tide them over, while never finding the security of sustained, long‐term funding that would allow them to focus on the actual work, and make long‐term plans.

It is also important to note that the secure funding provided through the S2S program helped ensure that HealthBridge’s partners could make significant contributions not only to national, but also international tobacco control, such as at in‐country, regional, and international negotiations for the FCTC, at other regional and international workshops, and by occupying key positions and contribution to international networks such as the Framework Convention Alliance (FCA).

Lesson learned: Much advocacy work consists of communicating with other NGOs and with government officials, and the main costs involved are thus office space, communications, and salaries. Overhead support for these costs is vital to the effectiveness of the work, and grants to support tobacco control should include and possibly even prioritize such “unglamorous” recurrent costs, as opposed to focusing on specific, short‐term, but possibly less effective projects. This will also help ensure that advocates can contribute to international as well as local tobacco control advocacy.

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XII. Importance of supporting sustained activities, not just capacity building/workshops

Many experienced, skilled people are working around the world on tobacco control. Their biggest problem may not be lack of knowledge or skills, but rather lack of funding for their day‐to‐day activities. While capacity building activities including workshops can be very useful to the work, and can improve networking across countries, such activities should not take precedence over funding for people’s actual work.

In addition, when people from under‐funded programs attend workshops in expensive hotels, where much money has been spent flying in “experts” and participants from many countries, they may experience jealousy or anger at the amount of money spent, especially when even relatively small funds are not available for them to carry out their campaigns. It is also difficult to justify asking such participants to work actively in their own countries, when the funds are not available to them to carry out the work about which they learned at the workshops.

Lesson learned: Much expertise already exists in tobacco control, and funding should focus on assisting existing, skilled activists to carry out their daily work, rather than focusing on high‐cost, short‐term workshops which may in the end achieve little, due to the lack of sustained funding for the participants in their home countries.

XIII. Importance of supporting highly skilled local activists and NGOs rather than just a “fly in the expert” approach

There are many experts in tobacco control whose expertise can no doubt benefit programs in many countries, especially where such programs suffer from a lack of ideas, creativity, or appropriate solutions to the issues faced. On the other hand, the occasional visit of an expert will not bring about any sustained policy changes. Such changes require the on‐going, sustained commitment of local activists. Given the expense involved in the “fly in the expert” approach, consideration should be given as to whether such visits truly complement work on the ground, or exist in its absence, in which case the investment is likely to be wasted.

Lesson learned: Attention should be given to supporting local activists and NGOs, and ensuring that international experts complement rather than supersede in‐country programs.

* * *

WBB Case Study WBB plays a unique role in the NGO sector in Bangladesh. Its multi‐faceted contributions include serving as a training ground for other NGO staff, clearinghouse for information for government, media, and other NGOs; a drop‐in

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center; and a secretariat to four alliances. WBB also makes an active effort to build the capacity of its own staff, and to give young people the chance to make significant contributions in the field of development. Many of WBB’s activities are carried out to some extent by the other NGOs in its network, but unfortunately the demands of project implementation often makes it difficult to serve other NGOs to the extent WBB wishes.

Training ground for other NGO staff

Many small NGOs lack office space and personnel to house and train new staff; as a result, they are unable to expand their programs. In order to address this need and to acknowledge and support the great contributions that small NGOs can make to policy (it is often much easier to move a small NGO than a large one, due to the lack of bureaucratic hurdles), WBB offers office space and training to staff of three BATA member NGOs. Each NGO has one staff member who works regularly in the WBB office under the joint supervision of WBB tobacco control staff and an officer from their NGO, who usually drops in during the evenings.

In addition, WBB provides training opportunities for volunteers and young staff. WBB itself consists mostly of young people hired with little or no previous experience who receive on‐the‐job training and ample encouragement and responsibility. One success story is a young woman who began as a volunteer and was later hired by WBB as project officer for its Ecocities project.

Clearinghouse for information for government, media, and other NGOs

WBB has an extensive print and video library, and regularly brings updated materials from international conferences. WBB staff members also regularly communicate via listservs and gather information through the Web. In addition, WBB’s continual communication with government officials and network members means that its staff members are always up to date on developments in tobacco control. As a result, WBB is a key source of information for different agencies. Journalists, including TV, regularly visit the WBB office to gather information from the staff about the current situation on law enforcement and other measures.

Drop‐in center

Although it is perhaps a poor model of balancing work and family life, WBB’s office is open until 9 or 10 p.m. most days, as well as on many holidays and hartals (political strikes). People can come to WBB at any time without an appointment, and many drop in after their own working day is over. As a result, communication with network members is greatly facilitated, and many people meet each other at WBB, leading to greater collaboration.

Secretariat to four alliances

WBB Trust is the Secretariat not only for the Bangladesh Anti‐Tobacco Alliance (BATA), which is the key alliance pushing tobacco control in Bangladesh, but also

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for alliances working on noise pollution, polythene and plastics reduction, and fuel‐free transport (Roads for People). In its role as Secretariat, WBB not only organizes meetings and maintains regular contact with its members, but encourages them to organize activities and to engage in relevant policy‐related work. When needed, WBB provides media and documentation support, which includes contacting journalists (electronic and print), preparing and sending press releases (by fax and in person), taking still photos and video footage, and collecting news coverage and forwarding it to policymakers.

How WBB’s work in tobacco has contributed to other areas

WBB’s work in tobacco control has provided critical experience and lessons for its work in other programs as well. For example, WBB staff learned that government officials are often very responsive to letters (and, at least in the context of Bangladesh, far less so to e‐mails). This has allowed other programs to gain rapid connection with relevant government agencies through appropriate use of written communication, followed up with phone calls.

WBB’s media network, developed over the course of its tobacco control work, has proved extremely important to its other programming. For example, when WBB started working on its transport policy program, journalists were highly skeptical of the information WBB provided. But they listened, and within a few months, they began to come around. As one journalist put it, “We know that WBB does really good work, and we want to believe you, but it’s very difficult!” Starting from scratch at building a network of media personnel while working on such a difficult and controversial issue would have required substantially more time and effort.

WBB attempts to be a “model” NGO in other ways as well:

In‐house capacity building: WBB’s in‐house international advisor (HealthBridge’s Regional Director, based in WBB’s office) regularly gives presentations on different subjects attended by all staff, with topics as diverse as results‐based management, ecocity design, how TV harms public discourse, how environment and women’s work are ignored in GDP, the burdens faced by working families, and the history of consumerism in the United States.

Office meetings, collaboration: while each WBB staff member works on a specific program, different programs support each other, and all staff members update each other about their programs through weekly office meetings, as well as informal meetings and participation in each other’s events. Thus lessons learned on media work, research, advocacy, networking, and so on are regularly shared across programs.

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Young staff: WBB staff are recruited generally at a young age (25 and under) and with no previous work experience. Young people are given the chance to learn and grow, and given professional, policy‐related work for which they have responsibility, with of course appropriate guidance from more senior staff. The oldest person in the office is under the age of 45.

Close collaboration with media: electronic and print media frequently come to the WBB office for information. The national radio program, Betar Bangladesh, regularly records talk shows at the WBB premises, with WBB putting together the script and inviting the speakers. WBB has provided scripts and footage to TV programs, and maintains close, friendly relationships with many journalists.

Conclusion

The knowledge base on tobacco control has grown enormously over the past few decades. Abundant research exists on the ways tobacco harms health, the environment, and economies, and contributes to poverty. Guides also exist on practical aspects of tobacco control, such as desired content of law and ways of increasing implementation. But there is always room for more sharing.

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This document discusses key lessons learned over the course of a multi‐year, multi‐country tobacco control program. It is hoped that the information in this document will help funders in making important decisions about resource allocation, and those involved in the day‐to‐day challenge of reducing tobacco use to overcome common obstacles and gain ever‐greater successes. By working intelligently and sharing key lessons, the tobacco control movement can overpower the industry and ensure that laws and policies are meant not to further enrich the wealthy, but rather to improve the lot of people overall.


HEALTHBRIDGE