Strengthening the Role of Organized Civil Society in the Struggle to Control the Tobacco Epidemic

Introduction

Tobacco products currently cause more deaths worldwide than does HIV/AIDS. While smoking rates are lower in Brazil than in neighbouring countries, at 19% it still amounts to some 35 million people. As in other countries, tobacco use in Brazil is higher among lower-income segments of the population, thereby increasing health and poverty inequalities. Brazil also has a comparatively large tobacco-farming sector, and is in fact the world's largest exporter of tobacco leaf. The sector has been growing in recent years, and is expanding from the south of the country to the poorer northeast.

In most countries where tobacco control advances have been made, they were the product of the co-operative work of individuals and organizations both inside and outside government. This is not the case in Brazil: Brazil is unique among major democracies in having relatively extensive tobacco control policies that were developed and implemented almost entirely through government initiative. Unfortunately, in a political system as vast and fragmented as Brazil's, policy coherence across government has been difficult to achieve. The lack of policy coherence can be explained in part by the historical general absence of NGOs from the tobacco issue. Given the number of extremely active Brazilian NGOs on many other social and health issues, this absence was surprising.

The overall long-term goal of this project was "To contribute to the greater achievement of equity in Brazil while reinforcing bilateral relations between Canada and Brazil, by working bilaterally to reduce Brazil's burden of death, ill-health and social and economic inequity attributable to tobacco use and production." Its purpose was to "Increase the participation, credibility, and role of civil society in tobacco control."

Objectives

The objectives of the project were:

• To strengthen civil society capacity to participate in public debate & influence public policies related to tobacco control, particularly addressing social & economic inequity.
• To improve Brazilian capacity to undertake gender-sensitive research for advocacy and policy analysis on TC.
• To strengthen governmental support for the development and implementation of gender-sensitive tobacco control measures.

Results and Impact

In collaboration with local partners, the Project team designed and implemented a range of activities that were also complementary to other tobacco control activities being implemented in the country.

The activities implemented by the Project team addressed 9 specific categories including: networking, advocacy, working with government, capacity building and technical assistance, media engagement, information sharing, research, reputation building, and international engagement. No one set of activities was confined to a objective; likewise, no single objective was comprised of a single set of activities, demonstrating the project's multi-dimensional character and the fact that many activities served a number of purposes as they were implemented and completed.

Outcome 1 addressed the need to foster, support, and build the capacity of civil society in tobacco control to ensure that there could be more effective engagement of a wide range of sectoral perspectives in the development, implementation, and monitoring of tobacco control policies. The design of this Outcome recognized that to engage civil society more broadly, there first needed to be single focal organization that could take the lead in advocacy, issue identification, and attracting other organizations.

Significant achievements were noted for this objective: hundreds of Brazilian organizations have become engaged in tobacco control; in fact, ACT is now larger than any tobacco control organization in Canada, and indeed is probably the second largest tobacco­specific tobacco control advocacy organization in the world. The tobacco control debate has been expanded far beyond health: as members of a multi-sectoral coalition, ACT's members approach tobacco control from many different angles, each according to its area of expertise. This has helped to raise the profile of tobacco control as a multi-sectoral issue across the country. Tobacco control has been integrated into the agendas of a wide cross-section of sectoral organizations. Through its positive relationships with several government agencies, ACT has solidified its reputation as a trusted civil society partner. As a result, it sits on a number of state and municipal committees focused on tobacco control, thereby ensuring that the voice of civil society is heard. ACT is recognized as a credible and reliable source of information by the government, the media, and the public. While a dedicated and sustainable domestic source of funding for tobacco control has not been achieved, Brazilian tobacco control organizations have established partnerships and relationships with international donors which will ensure the accessibility of funding in the coming years.

Outcome 2 addressed the need to foster, support, and build the capacity of Brazilian researchers to identify and address gaps in tobacco control research in the Brazilian context. The design of this Outcome recognized that to foster sustainable research, there needed to be a source of funding that was both accessible and applicable to Brazilian researchers.

A number of important results were achieved related to this outcome: a foundation has been established for, and preliminary results achieved from, gender-focused tobacco control research that will guide the development of gender-sensitive tobacco control policy in the future. A mechanism has been created that will facilitate the management of future small grants processes for Portuguese-language researchers. Key gaps and weaknesses in existing Brazilian tobacco control legislation have been identified, and technical policy analysis skills built, allowing for targeted advocacy action. The judiciary and legal profession has become engaged in tobacco control. Policy-relevant research has created an evidence base that supports tobacco control policy development and implementation in line with Brazil's FCTC requirements.

Outcome 3 addressed the need to strengthen government interest and political will to address tobacco control in a way that would be coherent across many sectoral issues. The design of this Outcome recognized the need to both build knowledge among politicians and legislators and engage their interest. It was also based on the need to debunk tobacco industry propaganda.

Several important results were also achieved associated with this outcome: government engagement in and support for tobacco control measures - particularly smoke-free environments - has increased significantly, especially at the state and municipal levels. A domino-effect passage of smoke-free laws has taken place at the state and municipal levels; about half of the Brazilian population is now protected from second-hand smoke in public places. The groundwork has been laid for the development and passage or strengthening of tobacco control measures in other areas, including advertising bans and taxes/prices.

Measuring health impacts stemming from a relatively short-term project as this is difficult if not impossible. However, the project has successfully laid the groundwork necessary to effectively contribute to reduced death and ill-health from tobacco use in Brazil. It has done so, in part, by fostering the passage and implementation of smoke-free laws, which will significantly reduce exposure to second hand smoke in public places (and thereby reduce the related health risks). While any reduction in smoking rates cannot be directly attributed to the activities of this project, it can be noted that the project has contributed to public awareness about the harmful effects of direct and passive smoking and to the development and passage of tobacco control regulations which will help to protect the population from the harms of tobacco.

Thanks to the significant progress that has been made in tobacco control through this project, ACT is now very well placed to continue to lead civil society action in Brazil and to bring the Brazilian government closer to meeting its Framework Convention on Tobacco Control obligations. Its ability to access international funds and to play a leadership role worldwide - together with the policy changes now underway in Brazil - point to the sustainability of the results achieved through this CIDA-funded project.

For more details on these and other results, please see the final project report.

Lessons Learned

Several key lessons were learned during the implementation of this project:

• Activities that depend on negotiations involving players from various governmental and non-governmental sectors are challenging and the timing does not always follow expected schedules. It is also possible to find partners in the most unexpected places; it is therefore important to never close doors when outcomes involve political negotiations.
• The decision-making process in Canada is significantly different from the decision-making process in Brazil. Although anticipated to some extent, this has had implications on the issue of technical cooperation and knowledge exchange (in the sense that some Canadian expertise is less relevant to the Brazilian context than originally expected). The very rapid growth of ACT meant that informal types of knowledge exchange (i.e. e-mails, phone calls and side meetings at international events) were shown to have been at least as important as formal, workshop-type training events.
• In situations where the tobacco industry's influence causes balking at the federal level to pass a comprehensive tobacco control law, addressing tobacco control from a number of different perspectives can generate support from a wide variety of constituencies. Two key examples of this approach were addressing tobacco control as an occupational health hazard, which gained the attention and support of labour prosecutors, and addressing tobacco control from a legal point of view, which enabled the project team to engage the Brazilian judiciary and prosecutors.
• Partial tobacco control measures can actually be more difficult to improve than having no measure at all. For example, the existence of a partial tobacco advertising ban in Brazil meant that there was little initial support to do further work in this area. Given the many ways that the tobacco industry was violating even the existing advertising ban, including setting up "temporary points-of-sale" at parties organized for young people, the project team identified many opportunities to demonstrate how the law needed to be strengthened and to gain the support of politicians. Public opinion polls and a documentary were used to educate the public about the pervasiveness of tobacco advertising and its impact on youth smoking initiation, and thus to generate support for tighter controls on such advertising.
• 5. The tobacco control community sometimes reinforces traditionally negative gender roles and has not been not very successful addressing women's needs and society's unbalanced social relations. The engagement of women's and feminist organizations in tobacco control has thus historically been weak. There have also been few resources available to encourage their involvement. However, by mapping the engagement of women’s organizations in tobacco control, providing training around the incorporation of a gender perspective into tobacco control research, and making funds available for the completion of six research projects, the project team raised awareness within the feminist movement of the importance of addressing tobacco control. In particular, one of the research studies undertaken specifically addressed the issue of how to engage the women’s/feminist movement in tobacco control. World No Tobacco Day 2010 will focus on gender, and this will help to further promote the development of activities with women's organizations.

Recommendations

Even with the ending of the CIDA-funded program in Brazil, a number of next steps have been identified:

• To increase advocacy efforts for a federal smoke free law in Brazil
• To support the development of a bill for cigarette ad ban and to support its approval, implementation, and enforcement
• To undertake studies on the issue of tobacco prices and taxes, as well as to further engage civil society, government, and border country authorities in activities addressing the illicit trade of tobacco products
• To further engage gender organizations in the ACT network
• To development and implement a new project focusing on youth and university collaboration (will probably be funded by J&J)
• To share ACT's experience with other national and international organizations, through events and publications
• To continue the monitoring of FCTC implementation in Brazil
• To continue collaboration and knowledge transfer between HealthBridge and ACT, as well as engaging other Canadian and Brazilian organization