How do tobacco control policies work in low-income and middle-income countries? A realist synthesis

Abstract

BackgroundThe burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs.MethodsWe conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs.ResultsWe included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process.ConclusionsThe synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs.PROSPERO registration numberCRD42020191541.

Global smoking-related deaths averted due to MPOWER policies implemented at the highest level between 2007 and 2020

“…Here, different policies may be more effective in different areas of the world [21,49]. Therefore it is important to consider each country's stage in the smoking epidemic [50] as well as their economic, cultural and political determinants [25,51] in the progress and overall evaluation of the impact of MPOWER policies. This is perhaps evident in the uptake of P policies where less than half of all LIC have implemented them and when implemented the overall influence of the policy was low, reaching one in 100 smokers.…”

How does Indian news media report smokeless tobacco control? A content analysis of the gutka ban enforcement

“…Likewise, enforcement was dynamic when champions led the inspection drives and there was access to information (tip-offs) and high-level support. Rewards in the form of cash (n = 2) were also a motivating factor, which relate to two studies arguing that the effect of enforcement is stronger when officials are compensated by the fines collected [ 43 , 44 ]. Several barriers raised by the news are consistent with global and Indian tobacco control literature, particularly with regard to gutka, where legal loopholes, lack of awareness and enforcement, and litigation by tobacco industries are associated with violation of the ban, sale of twin packets, without mandated health warnings [ 31 , 45 , 46 ].…”

Smoking cessation interventions and implementations across multiple settings in Japan: A scoping review and supplemental survey

“…To the best of our knowledge, few studies have focused on smoking cessation interventions with an implementation science perspective worldwide, with research being conducted primarily in hospital settings [15][16][17][18][19] and a few in non-hospital settings [20][21][22][23], and no reviews have covered settings such as hospitals, communities, workplaces, and schools. Since the implementation of smoking cessation interventions varies globally, and even within countries despite the existence of global and national tobacco control policies [24], there is a need for studies focusing on implementation in a wide range of settings in a speci c country.…”