Contextual factors impacting WHO Framework Convention on Tobacco Control implementation in Africa—a scoping review

Abstract

According to the World Health Organization (WHO), tobacco use causes over 8 million deaths annually including 1.3 million due to second-hand exposure. Furthermore, data from the Tobacco Atlas show that the tobacco industry continues to target new markets in the WHO African region, one of two regions where absolute numbers of smokers continue to increase. Understanding context contributes to policy formulation and implementation ensuring relevance to a country’s political economy. Focusing on the WHO African region, this scoping review (i) maps the extent of academic research examining contextual factors on the WHO Framework Convention on Tobacco Control (WHO FCTC) national-level implementation, and (ii) reports on contextual factors impacting the WHO FCTC implementation. Using a stepwise structured approach, we conducted a search across four academic databases, yielding 10 342 articles and 42 were selected for full data extraction. Leichter’s four categories of context (situational, structural, cultural and exogenous) and the stages of heuristic policy model guided data extraction. Study findings indicated that situational contextual factors such as the burden of disease or its impact on health can push governments toward policy formulation. Structural contextual factors included political considerations, economic interests, funding, institutional congruence, strength of policy and institutional capacity as important. Cultural contextual factors included the influence of policy entrepreneurs, current social trends and public opinion. Exogenous contextual factors included the WHO FCTC, tobacco industry influence at the national-level and bi-lateral partnerships. Further understanding contextual factors affecting the WHO FCTC national implementation can strengthen policy formulation and align required support with the WHO FCTC Secretariat and other relevant bodies.

INTRODUCTION

According to the World Health Organization (WHO), tobacco use causes over 8 million deaths each year including 1.3 million due to second-hand exposure (Reitsma et al., 2021; World Health Organization, 2023a). While there has been a decrease in the prevalence of tobacco use from 22.7% in 2007 to 19.6% in 2019, the total number of tobacco users remains high (Drope et al., 2022). Over 80% of the world’s 1.3 billion tobacco users—including smokers and those who use smokeless tobacco—live in low- and middle-income countries (LMICs) (Reitsma et al., 2021; World Health Organization, 2023a). In addition to the harms of consumption, tobacco farming causes significant environmental and societal damage due to deforestation, child labour and multiple health hazards associated with tobacco leaf growing and processing (Leppan et al., 2014). A recent study found an increase in tobacco use among youth in 63 of the 135 countries surveyed and highlighted that the tobacco industry continues to target new markets in the WHO African region (referred to as African region from here on) (Drope et al., 2022). The African region is one of two WHO regions that continue to see absolute numbers of smokers increase (Drope et al., 2022).

To stem the global impact of the tobacco epidemic, the WHO Framework Convention on Tobacco Control (WHO FCTC) was adopted by the World Health Assembly in 2003, and came into force 2 years later (World Health Organization, 2005; Chung-Hall et al., 2019). WHO FCTC is a legally binding global health treaty that requires acceding countries to implement measures outlined in the treaty for supply and demand reduction of tobacco (World Health Organization, 2005; Chung-Hall et al., 2019). As of February 2024, 183 parties out of 193 have either ratified or acceded to the WHO FCTC (United Nations, 2023). The provisions of the WHO FCTC cover both demand reduction (reduction of consumption) and supply reduction (reduction of tobacco growing and tobacco product manufacturing) measures (World Health Organization, 2005). Early estimates suggested that without substantial advancement in WHO FCTC implementation, an estimated 1 billion people are expected to die from tobacco-related deaths in the 21st century (Jha et al., 2006). The impact report of the first decade of the WHO FCTC implementation, WHO Report on the Global Tobacco Epidemic, 2021 and more recent analysis of the WHO FCTC country-level impact highlight the positive impact that WHO FCTC implementation has had globally in reducing tobacco use and the corresponding need to strengthen implementation efforts in LMICs (Chung-Hall et al., 2019; World Health Organization, 2021b; Paraje et al., 2024). The Global Strategy to Accelerate Tobacco Control 2019–25 also notes the need to strengthen WHO FCTC implementation strategies (World Health Organization, 2019).

We have operationalized the ‘implementation of WHO FCTC’ as national-level development and enforcement of policies based on WHO FCTC commitments.

Comprehensive implementation of the WHO FCTC in the African region is particularly urgent as many have suggested that the continent is the next epicentre of the tobacco epidemic (Blecher and Ross, 2013; Egbe et al., 2022; Worth, 2023). Of the 47 countries in the WHO AFRO region (one of six WHO regions focused on the African continent), 45 have either ratified or acceded to the WHO FCTC (United Nations, 2023; World Health Organization, 2023b). The most recent signee to the convention was Malawi in August 2023. The African region remains of high interest to the tobacco industry due to its youthful population, economic promise, expected population growth and the fledging state of tobacco control measures in many countries (Vellios et al., 2018; Egbe et al., 2022; World Bank, 2023). Unregulated markets, weak policies or strong policies with weak policy enforcement, are some of the challenges that require attention in the region (Vellios et al., 2018; Egbe et al., 2022). Many of the top tobacco-growing countries are located in the region, creating conflicts of interest within governments where tobacco is viewed as an important economic commodity (Lown et al., 2016; Lencucha et al., 2018; Smith and Lee, 2018; Fang et al., 2020).

Recognizing the urgency and importance of comprehensive implementation of the WHO FCTC, it is crucial to strengthen policy environments and support actors in tobacco control, especially at the national level. The WHO FCTC implementation requires a national government mandate, resource allocation, inter-ministry cooperation and coordination, public awareness building, collaboration with non-governmental organizations, mechanisms to counter tobacco industry influence and many other factors, which vary by country context (World Health Organization, 2021a). Bump and Reich pointed out that comprehensive tobacco control implementation in LMICs demands an understanding of the political economy at the country level (Bump and Reich, 2013). Macro-economic changes (e.g. recession, country-level debt, new trade agreement), institutional culture (e.g. mandates that favour free market principles over social protection), relationships with state and non-state actors (e.g. viewing industry as a legitimate stakeholder), resource availability (e.g. budget allocations for policy implementation) and organizational capacity (e.g. human resources and technical capacity) are realities that need to be taken into account (INASP and Politics and Ideas, 2016). These factors all inform an understanding of the context of policy implementation (Daniels, 2018; Browne et al., 2019). Given the importance of context in shaping research on and implementation of the WHO FCTC implementation, a critical examination of how the context of the WHO FCTC implementation is researched, what contextual factors have been found to shape implementation, and what further research and conceptual development is needed (Wisdom et al., 2018; Egbe et al., 2022).

In this review, we consider the published academic literature on the WHO FCTC implementation in the African region with a focus on contextual factors impacting implementation. We examine contextual factors influencing policy formulation, enforcement and evaluation at the national level, with a view to informing the direction of future research and strengthening the WHO FCTC implementation. This scoping review first maps the extent of academic research examining contextual factors on the WHO FCTC implementation at the national level and then synthesizes and collates the data relevant to the WHO FCTC implementation in the African region.

METHODS

Scoping reviews are a form of systematic knowledge synthesis, which involve the comprehensive search, collation and analysis of available literature on a specific topic. They aim to identify and map the available evidence, with the purpose of informing practice, programmes and policy and/or providing direction to future research priorities (Pham et al., 2014). We used a scoping review, as opposed to a systematic review, as our goal was to map a broad range of academic literature and identify the topics addressed in the research on context. We did not aim to assess the quality of evidence or answer a more targeted question on WHO FCTC implementation. Therefore, scoping review was the best fit for this research to examine the broad range of literature on our selected topic, while ensuring rigor in the search and analysis process (Munn et al., 2018). We used scoping review methods to identify the published literature on how context is considered in tobacco control research in the African region. We employed the enhanced scoping review stepwise methodological framework of Levac, Colquhoun and O’Brien, which builds upon the earlier framework of Arksey and O’Malley (Arksey and O’Malley, 2005; Levac et al., 2010). Based on this framework, we follow five steps in our review: (i) identifying the research question, (ii) identifying the relevant studies, (iii) study selection, (iv) charting the data and (v) collating, summarizing and reporting the results. Levac et al. provide further recommendations related to data extraction, data collation and reporting stages. First, as advised by Levac et al., two authors reviewed the first five publications to establish consensus before moving on to full data extraction. Second, we divided our data reporting to descriptive statistics and qualitative analysis-based reporting (Levac et al., 2010). To guide our review, we drew on Leichter’s four categories of context and the stages heuristic policy model (Collins et al., 1999; Walt et al., 2008; Kent et al., 2012).

Conceptual model and framework

Context is a broad term and can be defined in different ways (Collins et al., 1999; Kent et al., 2012). In this review, we employ Leichter’s framework that conceptualizes policy context into four distinct categories (Supplementary File 1): (i) situational factors that impact policy such as pandemics or natural disasters, (ii) structural factors stemming from economic factors, governance or institutional norms, (iii) cultural factors rooted in social norms and socio-economic conditions and (iv) exogenous factors such as global health treaties, multinational industry influence or bi-lateral agreements (Leichter, 1979; Kent et al., 2012).

Given our focus on policy implementation in countries following the ratification of the WHO FCTC, we also reference the cyclical stages heuristic model initially introduced in 1956 and adopted and adapted by health policy researchers (Walt et al., 2008; McCarthy-Cotter, 2019). This model has five stages including agenda setting (getting the relevant topic on the government agenda), policy formulation (formulation of relevant tobacco control policies using WHO FCTC guidance), legitimation (gaining support from relevant actors, especially policy makers), implementation (enforcing the policies formulated via relevant institutions) and evaluation (evaluating the performance of policies) (Walt et al., 2008; McCarthy-Cotter, 2019). We used this model to examine how context applies to each stage of the cycle when implementing the WHO FCTC guidance in countries that have ratified the treaty. Together, Leichter’s context framework and the stages heuristic policy model provide helpful conceptual guidance in examining the national-level implementation of the WHO post-ratification, usefully informing all stages of analysis, including coding, data collation, interpretation and reporting.

Identifying the research question

The WHO FCTC implementation needs strengthening in LMICs and understanding context has strong relevance to improving policy implementation (Chung-Hall et al., 2019). We narrowed our focus to the African region given the increasing number of tobacco users in the region and the industry’s corresponding interest in the region as an emerging market (Adebiyi and Oluwafemi, 2017; Lencucha et al., 2022). Focusing on the African region and understanding the context can support goals such as improving institutional cooperation in the region, priority setting within funding organizations and identifying and applying lessons learned among countries that are acceding to the convention (Egbe et al., 2022). Thus, for this review, we pursue the question, what contextual factors have been examined in academic research on the WHO FCTC implementation in the African region? As noted in the introduction, under this research question, we examine research on contextual factors and their association with policy processes related to WHO FCTC.

Search strategy

For this review, we used Scopus, Web of Science, PubMed and Europe PMC databases with the goal of covering a wide range of relevant academic disciplines. Europe PMC was specifically included as it captures pre-prints from multiple other pre-print servers, making our search more comprehensive (Europe PMC, 2018). We developed a comprehensive research strategy with the support of experts from the library of the first author’s (S.B.) current institution that aimed to include national-, regional- and global-level studies, with a special focus on countries from the African region. Finalized through an iterative process, search terms focused on the following areas: context, tobacco control, WHO FCTC and implementation. Implementation within this review was operationalized as national-level policy implementation of the WHO FCTC inclusive of stages of the policy model. In addition, references of selected publications were searched for relevant additional publications to be included in the scoping review. Supplementary File 2 provides a compilation of search strings with specific search terms and Boolean operators categorized by each database.

Selecting relevant studies

Two authors (S.B. and R.L.) initially screened titles and abstracts of 100 articles out of 4760 to establish consensus on article selection based on inclusion and exclusion criteria (Table 1). Once consensus was established, S.B. screened the remaining articles for study selection. Inclusion criteria were articles that were pre-printed or published in peer-reviewed journals that focused on the implementation of the WHO FCTC at the national or sub-national level, including the stages of agenda setting, policy formulation, policy legitimation, policy implementation/enforcement and evaluation. The starting date for inclusion was set for 1 January 2004, 1 year before the WHO FCTC came into force, and our search end date was 25 October 2022. We conducted the search and extracted search results on 26 October 2022. Since the initial deadline to sign on to the WHO FCTC was 29 June 2004, we used 1 January 2004 (the beginning of the year), to ensure we did not miss any relevant articles. We excluded articles that did not discuss contextual factors such as prevalence studies that only reported the quantitative findings without connecting them to contextual factors. For title and abstract screening, we used Rayyan online tool and selected articles were included in an Excel table. From this table, we conducted full-text screening for studies that needed more in-depth review to select the final set of studies for data extraction.

Data extraction

The first author (S.B.) created the initial data extraction table and incorporated team feedback to improve and finalize the table. R.L. and S.B. then conducted data extraction on five publications to establish consensus. In addition to descriptive data such as authors, date and title, the data extraction table was designed to extract and collate data from each study related to each contextual factor (situational, structural, cultural and exogenous) and categorized each study under relevant policy stage(s) of the stages heuristic policy model.

Analysis and reporting of results

We conducted two levels of analysis. First, we conducted a descriptive analysis to categorize the publications by geographic focus, what contextual categories the data belonged to in each publication, and which policy cycle stage(s) each publication addresses. Second, we conducted inductive thematic analysis within the four contextual categories. In this analysis, we coded the extracted data and identified common themes applicable to all countries with specific examples from different countries. We report these examples in the results section to illustrate how contextual factors were integrated in the study findings on policy processes. Finally, we identified the stage of the policy cycle addressed in the publication.

After conducting the search across four databases, we generated an initial list of 10 342 articles. From this initial list, we removed 5582 duplicate articles and identified 4760 articles for screening. After the title and abstract screening, we finalized 50 articles for full-text screening. Following the full-text screening, we selected 42 articles for extraction. The screening process is illustrated in Supplementary File 3.

RESULTS

Descriptive results of the included publications

Based on our analysis of the geographic distribution of publications, the largest number of academic publications focused on Kenya (n = 11), followed by South Africa (n = 5), then Ghana, Nigeria, Ethiopia, Uganda and Mauritius, all with four publications each. Other countries represented within this review include Zambia (n = 3), The Gambia (n = 2), Madagascar (n = 2), Cameroon (n = 2), Togo (n = 2), Namibia (n = 1), Senegal (n = 1) and Zimbabwe (n = 1). There are also publications focused on the African region (n = 6) and the West African region (n = 1) (Supplementary File 4).

Our analysis identified one or more contextual factors in each of the publications. As individual publications had content related to more than one contextual category and policy cycle stage, the total number of contextual categories or policy cycle stage represented exceeds the total number of publications included (Supplementary File 5). The structural contextual factor had the highest frequency across included publications, figuring in 39 of the 42 articles reviewed. Situational contextual factor (6) had the lowest. Cultural and exogenous had 20 and 26 publications, respectively. Policy implementation stage had the highest frequency with 36 publications referring to it. Policy formulation, legitimation and evaluation had 15, 18 and 11 publication references, respectively.

Qualitative analysis results of contextual factors

We report the qualitative results using Leichter’s four categories.

Situational contextual factors

Situational factors refer to acute, less repetitive, factors that impact policy and policy environments, including armed conflict, epidemics or pandemics, natural disasters and similar events (Kent et al., 2012). Across the reviewed publications, situational factors were found to be the least frequently referenced factor in relation to the implementation of the WHO FCTC. Examples of situational factors identified included high-level disease burden due to tobacco use or increasing trends in tobacco use and political instability impacting agenda setting, policy formulation, legitimation and implementation (Patterson and Gill, 2019; Habebo and Takian, 2020; Singh et al., 2020; Egbe et al., 2022). Of particular note was the recognition that despite the comparatively low prevalence of tobacco in the region, the trend of increasing tobacco use is a situational factor that is relevant to the WHO FCTC implementation (Patterson and Gill, 2019; Egbe et al., 2022). For example, one study noted that in Nigeria, the steady increase in tobacco-related illness prompted eight states and the federal government to file lawsuits against British American Tobacco Nigeria (BATN) (Udokanma et al., 2021). Another study in Kenya noted that increased tobacco use was recognized by the public as a health challenge and by stakeholders within the health ministry as both a public health and environmental challenge (Mohamed et al., 2018). Additionally, one study conducted in Ethiopia, found that the volatile political climate caused impediments to policy implementation even when national-level policies for tobacco control were in place (Habebo and Takian, 2020).

Structural contextual factors

Structural contextual factors include more permanent elements of society such as economic structure, political system, degree of urbanization and demographic structure (Kent et al., 2012). Based on our analysis, 39 studies referred to structural factors in their analysis of the WHO FCTC implementation (Supplementary File 5). We organized the analysis of the structural factors under six sub-themes: political, economic, institutional capacity, funding, strength of policy and institutional coherence.

Political

At the national level, policy formulation processes were attributed to political contextual factors. For example, the passing of Nigeria’s tobacco control act required political support to finally be enacted in 2015 (Udokanma et al., 2021). Delays by the then president in signing the bill, public opposition by political stakeholders to the bill, and internal divisions among stakeholders were significant political structural factors that were identified as challenges (Adebiyi and Oluwafemi, 2017; Udokanma et al., 2021). Ghana, being one of the first five countries to become party to the Convention in 2004, re-drafted the existing tobacco control Bill in 2005 despite initial delays and passed a comprehensive tobacco control law in 2012 (Owusu-Dabo et al., 2010; Singh et al., 2020). In 2018, Ghana also strengthened its tobacco control law with pictorial warnings on packaging (Owusu-Dabo et al., 2010; Singh et al., 2020). Multiple ministries including health, education and transport issued directives to ensure adherence with guidelines outlined in the WHO FCTC soon after ratification (Singh et al., 2020). Despite initial delays, strong political will was cited as a key impetus by stakeholders in getting a comprehensive tobacco control bill passed in Ghana (Singh et al., 2020). Other examples include studies that attributed political alignment and support to successes in countries such as Senegal, Namibia and Kenya where comprehensive policy instruments reflecting the WHO FCTC were formulated and enacted (Tam and van Walbeek, 2014; Mohamed et al., 2018; Sagna et al., 2022). In South Africa, the African National Congress framed the harms of tobacco use as a racial-equity issue in efforts to strengthen the political will to counter pro-tobacco lobbying (Wisdom et al., 2018). Mauritius also stands out in the region as a country where the government’s full commitment was cited as a key factor in formulating national policies to implement the WHO FCTC (Kusi-Ampofo, 2021).

Economic

Prioritization of tobacco as an economic commodity in public policy and government institutions is another structural factor that was found to impact policy formulation, enactment and implementation (Lencucha et al., 2016a, 2016b; Erku and Tesfaye, 2019; Egbe et al., 2022). For example, countries such as Zambia and Ethiopia were found to have economic interests that clashed with implementation of the WHO FCTC (Lencucha et al., 2016a; Ralston et al., 2022). This clash resulted in delays in enacting comprehensive tobacco control policy and the adoption of policies with loopholes that negatively affected implementation (Lencucha et al., 2016a; Habebo and Takian, 2020; Ralston et al., 2022; Kaai et al., 2023). In Zambia’s case, government investment in promoting tobacco as an economic commodity and in Ethiopia’s case, its state-owned tobacco industry monopoly, which was later privatized, were identified as factors shaping its approach to tobacco control (Lencucha et al., 2016a; Ralston et al., 2022). Other examples include countries such as Cameroon and Zimbabwe where economic contextual factors were found to impact comprehensive whole-of-government policy enactment to implement the WHO FCTC (Mapa-Tassou et al., 2018; Egbe et al., 2022).

Institutional capacity

Institutional capacity, both in terms of human resources and technical knowledge, remains a key structural contextual factor that impacts policy formulation, policy implementation and evaluation (Owusu-Dabo et al., 2010; Tam and van Walbeek, 2014; Mohamed et al., 2018; Jallow et al., 2019). In Namibia, a lack of legal expertise and staff capacity significantly impacted policy formulation processes within the government (Tam and van Walbeek, 2014). One study suggested that Namibia struggled to implement the 2010 Tobacco Products Control Act due to insufficient staff and legal capacity and tobacco control not being the primary priority of staff (Tam and van Walbeek, 2014). Insufficient legal knowledge among ministry officials was also reported as a factor that led to situations in which the ministry officials were vulnerable to being misled by industry (Tam and van Walbeek, 2014). In countries such as Ghana, Gambia and Kenya, studies attributed the lack of human resource capacity to challenges in sustaining the implementation of national tobacco control policies, including advocating for amendment processes when required (Owusu-Dabo et al., 2010; Mohamed et al., 2018; Jallow et al., 2019; Singh et al., 2020). Furthermore, in Ethiopia and Uganda, studies identified a lack of awareness among government officials outside of the Ministry of Health about tobacco control legislature and the WHO FCTC as a factor that hampered whole-of-government implementation efforts, especially in relation to minimizing industry interference (Hirpa et al., 2022; Male et al., 2022; Ralston et al., 2022).

Funding

Lack of funding for government policy-implementing bodies is cited by many studies as a factor limiting institutional efforts in formulating and implementing national-level tobacco control policies (Lencucha et al., 2016a, 2016b; Adebiyi and Oluwafemi, 2017; Mohamed et al., 2018; Singh et al., 2020). In Kenya, lack of funding was cited as a contributing factor for slow formulation of policies and the country had to rely on external funding to move policy formulation processes forward (Mohamed et al., 2018). In Zambia, studies indicate that stakeholders considered lack of funding to be a major factor impacting the approval of tobacco control legislature as tobacco control was not initially a priority within the health ministry (Lencucha et al., 2016a).

Lack of funding allocation stemming from poor leadership was noted as the cause of Nigeria’s weak performance in implementing Article 12 of the WHO FCTC (Adebiyi and Oluwafemi, 2017). In Kenya, lack of funding resulted in operational challenges for government entities, including the tobacco control board tasked with implementing and enforcing tobacco control policies (Lencucha et al., 2016b; Mohamed et al., 2018). In Zambia, it was suggested that lack of funding has affected the promotion of alternative crops for tobacco farmers (Lencucha et al., 2016a).

Strength of policy

The strength and comprehensiveness of the policy were found to be key factors when implementing the WHO FCTC. In Ghana, for example, until a comprehensive bill focusing on tobacco control was passed, there were implementation challenges despite having directives supporting the WHO FCTC implementation (Owusu-Dabo et al., 2010). Even passing legislation supporting the implementation of the WHO FCTC has been challenging as evidenced by the struggles in countries such as Kenya and Nigeria (Mohamed et al., 2018; Udokanma et al., 2021).

In other instances, even though tobacco control laws were passed, various loopholes hindered implementation. In Ethiopia and Uganda, the adaptation of Article 5.3 of the WHO FCTC (which focuses on managing industry interference) lacked adequate detailed policy tools for effective implementation (Ralston et al., 2022). With respect to the adaptation of Article 8 of the WHO FCTC related to smoke-free public places policy guidance, research indicates only 6 out of the 47 African region countries (Burkina Faso, Chad, Congo, Madagascar, Namibia and Seychelles) had enacted national policies or had sub-national laws protecting at least 90% of the population by 2015 (Husain et al., 2016). It is important to note that many countries, even those with comprehensive tobacco control policies, struggle to implement or enforce them due to structural contextual factors such as lack of institutional congruence, institutional capacity and resource availability (Egbe et al., 2022; Lencucha et al., 2022). Encouragingly, there are examples of how policy-focused research, and evaluation has been influential in shaping policy reforms that address structural factors related to tobacco control. For example, at the Conference of Parties of the WHO FCTC in 2012, the government of Mauritius cited data from the study Investigating the effectiveness of pictorial health warnings in Mauritius: findings from the ITC Mauritius survey by Green et al. (Green et al., 2014) as a reason to accelerate the revision of their pictorial health warnings.

Institutional coherence

Institutional coherence is dependent on the cohesiveness of actors within institutions. For example, poor coordination between different Ministry of Health entities in Kenya (e.g. NCD division, Office of the Chief Public Health Officer and Kenya Tobacco Control Board) was an important cause of implementation delays (Lencucha et al., 2016b; Mohamed et al., 2018). In Nigeria, a lack of political will was found to influence institutional coherence and whole-of-government approaches including delays in issuing policy announcements (Udokanma et al., 2021). In Kenya, despite coordination challenges, strong political will has been cited as a key factor in resolving challenges faced in implementing the national tobacco control policies led by the Ministry of Health (Mohamed et al., 2018). In countries such as Ethiopia, Zambia and Cameroon, tobacco control implementation also has been found to be affected by a lack of coordination and tensions between ministry priorities due to tobacco being a revenue source (Lencucha et al., 2016a; Mapa-Tassou et al., 2018; Erku and Tesfaye, 2019; Habebo and Takian, 2020; Hirpa et al., 2022).

Cultural contextual factors

Cultural contextual factors include socio-cultural norms, religious values and community participation (Kent et al., 2012). In relation to tobacco, the cultural context has been historically heavily influenced by the tobacco industry and related economic interests. This is largely why tobacco promotion and sponsorship bans have been such an important feature of the WHO FCTC. Within this review, we observed cultural contextual factors manifested in the use of media and prominent figures influencing institutional culture and shape public opinion. Studies found that media influenced prevailing culture via advancing the messages of policy entrepreneurs, as well as influencing societal norms and values relevant to tobacco control (Mohamed et al., 2018; Habebo and Takian, 2020; Udokanma et al., 2021). Moved by a visit to a children’s cancer ward, the First Lady of Kenya’s efforts to shift the culture on the WHO FCTC implementation at the highest levels of government is an example of a policy entrepreneur in action to affect institutional culture and sway public opinion (Mohamed et al., 2018). In Ethiopia, long-standing tobacco smoking practices in rural areas and smoking as a modern lifestyle practice among youth, are identified as socio-cultural factors impacting tobacco control implementation (Habebo and Takian, 2020). In Nigeria, studies suggest that had there been strong public pressure to pass the national bill on tobacco control it would have sped up the President’s signing of the bill (Udokanma et al., 2021). Rather, public engagement was found to be weak as the public awareness campaign was only initiated during policy implementation affecting overall societal socio-cultural awareness (Udokanma et al., 2021). Restriction of tobacco industry’s corporate social responsibility projects has also positively impacted media coverage of those activities in countries such as Botswana, Liberia, Gambia and Mauritius, which in turn impact public opinion and social norms (McDaniel et al., 2018). In addition to these cultural contextual factors, fabricated narratives, such as the lucrative nature of tobacco farming, also impact communities. For example, in Kenya, despite dismal profits and awareness building on the harms of tobacco farming, the narrative that tobacco farming is economically beneficial persisted. This narrative has largely been based on anecdotal evidence perpetuated by the tobacco industry, creating social norms and beliefs that create an unrealistic image of tobacco farming (Clark et al., 2020).

Exogenous contextual factors

Exogenous factors are factors from outside of the country influencing tobacco control such as the role of transnational companies, international agreements and other countries (Kent et al., 2012). The main exogenous contextual factors identified within this review are tobacco industry interference, the impact of the WHO FCTC and impact of other countries as development partners (Tumwine, 2011; Egbe et al., 2019; Zaatari and Bazzi, 2019; Fang et al., 2020; Hirpa et al., 2022; Ralston et al., 2022). In Nigeria, industry arm BATN played a significant role in delaying and interfering with the passing of tobacco control legislature (Udokanma et al., 2021). A key factor in industry interference in countries such as Kenya relates to their financial power over tobacco stakeholders, making it difficult to resist industry interference (Mohamed et al., 2018). Nigeria and Kenya, however, are not standalone examples. Industry interference remains a significant exogenous factor affecting the region while the shifting of attention of transnational companies to the African region as a new market for tobacco has been a deliberate strategy (Adebiyi and Oluwafemi, 2017).

The WHO FCTC as an international treaty has been found to be a key exogenous force in countering industry interference and a support to building government capacity to formulate, enact, implement and evaluate tobacco control policies at the national and sub-national levels (Tumwine, 2011; Lencucha et al., 2016a; Erku and Tesfaye, 2019; Singh et al., 2020; Udokanma et al., 2021; Egbe et al., 2022). Across the African region, governments have been persuaded, and at times pressured, to implement the WHO FCTC guidance at the national level (Adebiyi and Oluwafemi, 2017; Mohamed et al., 2018; Egbe et al., 2019, 2022; Singh et al., 2020). The WHO FCTC guidance related to taxation, minimizing industry interference and creating a smoking-free environment have been instrumental at the national level for all countries in the region, including Kenya, Nigeria, Gambia, Mauritius, Uganda, Namibia, both in terms of capacity building and creating legislature (Adebiyi and Oluwafemi, 2017; Mohamed et al., 2018; Erku and Tesfaye, 2019; Jallow et al., 2019; Singh et al., 2020; Ralston et al., 2022; Kaai et al., 2023).

Bi-lateral development partnerships are another exogenous factor that has impacted tobacco control in the African region in countries such as Zimbabwe and Ethiopia (Fang et al., 2020; Habebo and Takian, 2020). In Zimbabwe, China has played a crucial role in sustaining tobacco farming with bi-lateral assistance for tobacco farming through companies such as Tian Ze Tobacco Company, a subsidiary of China National Tobacco Corporation (Fang et al., 2020). China’s support was found to be a major factor in helping Zimbabwe recover from a declining tobacco industry in the early 2000s, contributing to China’s effort to establish itself as an ‘all weather friend’ (Fang et al., 2020). Ethiopia sold a controlling stake in its state-owned tobacco industry to Japan Tobacco International (JTI), a company in which the Japanese government has a controlling stake (Hirpa et al., 2022). JTI asserted Ethiopia to be an ‘important expansion of our geographic footprint in emerging markets’ citing the economic growth of Ethiopia as an encouraging factor (Hirpa et al., 2022).

DISCUSSION

This review has examined the contextual factors that have a bearing on tobacco control policy in the African region, from formulation to evaluation. Diving deeper into how contextual factors have affected policy processes is critical to strengthening ongoing and proactive research and policy action in the region (Chung-Hall et al., 2019; World Health Organization, 2021b; Egbe et al., 2022).

Based on the findings of this review, three key observations warrant discussion. First, studies suggest that situational factors such as rising burden of NCDs or cancer and higher rates of active Tuberculosis among tobacco smokers can serve as an entry point for policy formulation, processes including advocacy (Juma et al., 2018; Chidumwa et al., 2023). These factors can serve to effectively leverage cultural contextual factors (e.g. public opinion, media coverage, policy entrepreneurs) to catalyse implementation. Examples include the contention that the Nigerian president would have passed the tobacco control bill had there been more influence from the public (Egbe et al., 2019; Udokanma et al., 2021). By contrast in Kenya, public awareness regarding the consequences of tobacco use, and the First Lady’s role as a policy entrepreneur, helped expedite the enactment of tobacco control legislation (Adebiyi and Oluwafemi, 2017; Mohamed et al., 2018). Especially, using the rising burden of disease as a catalytic point for policy change requires effective monitoring of tobacco use or cost of tobacco use at the national level using prevalence studies and economic evaluations then connecting such data to media outlets and policy dialogues at the national level (Patterson and Gill, 2019). While the WHO has already recognized the need for such monitoring by implementing MPOWER measures, continued strengthening is needed at the national level (Wisdom et al., 2018). These measures include monitoring tobacco consumption and the effectiveness of preventive measures, protecting people from tobacco smoke, offering help to quit tobacco use, warn about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship and raise taxes on tobacco (World Health Organization, 2023c). This need for national-level strengthening of evidence-informed advocacy is an important observation relevant to research funders as well. Therefore, funders need to be cognizant and invest in long-term tobacco control research focused on strengthening community understanding, avoid rapid strategic shifts related to funding and avoid setting unrealistic outcomes to measure project success such as requiring rapid legislative change (Mohamed et al., 2018; Jallow et al., 2019; Patterson and Gill, 2019). For funders, it is essential to have a long-term approach that can provide resources to communities and strengthen advocacy.

A second observation is that structural contextual factors are the most commonly researched and/or identified category of factors shaping WHO FCTC implementation. An interconnected observation is the strong underlying impact of political determinants and institutional coherence on these factors (Adebiyi and Oluwafemi, 2017; Singh et al., 2020; Udokanma et al., 2021; Egbe et al., 2022). Expanding research that focuses on political determinants within policy processes can generate a deeper understanding of practices that other countries can learn from, especially within the region. As noted, it will also be important to understand the management of policy priorities in contexts where tobacco farming is considered an important source of revenue (Lencucha et al., 2016b; Fang et al., 2020; Lencucha et al., 2022).

Third, while tobacco industry interference has been well documented and examined in both academic and grey literature, it is still necessary to highlight that we noted industry presence as a key factor in all four contextual factor categories analysed in this review (World Health Organization, 2009; Assunta and Dorotheo, 2016; Male et al., 2022; African Tobacco Control Alliance (ATCA), 2023). This finding reiterates the importance of countering tobacco industry influence and further examining ways in which the industry impacts policy processes, especially in LMICs with emerging markets and good examples of successful strategies to mitigate the industry’s influence. An additional layer to this interference, as noted under exogenous contextual factors, is the bi-lateral partnerships offered by countries such as China and Japan to countries such as Zimbabwe and Ethiopia that work to further tobacco industry interests (Fang et al., 2020; Habebo and Takian, 2020).

Given the importance of understanding policy processes and political factors relevant to the WHO FCTC implementation, we believe that there is value in strengthening the evidence base via academic research. Based on our findings, we suggest three key considerations for further research focused on the context of the WHO FCTC implementation at the country level. First, is the importance of recognizing differing and common ways in which the tobacco industry operates in countries to impact policy and political processes. This knowledge is instrumental to building advocacy coalition efforts to counter industry interference. For example, in countries such as Zimbabwe and Malawi, where tobacco growing is a prominent feature of economic policy, the tobacco industry has strong inroads to policymakers as opposed to countries like Mauritius where this is not the case (Lown et al., 2016; Smith and Lee, 2018; Kusi-Ampofo, 2021). Additionally, it will also be important to understand the political and economic impact of bi-lateral influence that aligns with industry interests (Fang et al., 2020). Second, comprehensive analyses of wide-ranging contextual factors affecting policy and political processes will provide an understanding of which actors to support as key stakeholders and recognize policy entrepreneurs. This step will be critical to moving the policy advocacy agenda within the country. For example, civil society played a significant role in pushing forward Kenya’s tobacco control efforts (Mohamed et al., 2018; Wisdom et al., 2018). Finally, as political determinants are constantly changing, researching the impact of these dynamics on the WHO FCTC implementation process might help national and international actors, including funders, be more responsive. In Zambia, for example, a deeper contextual analysis of the political and policy process, including actors that are opposing and driving the WHO FCTC compliant legislation, might assist in overcoming implementation challenges (Worth, 2023). It will be helpful to examine the relative magnitude of the effects of these different contextual categories (situational, structural, cultural and exogenous). The recommendations for further research in the context of WHO FCTC implementation align with Global Strategy to Accelerate Tobacco Control 2019–25. In particular, our recommendations are reflected in Strategic Priority 2 (Building international alliances and partnerships across sectors and civil society to contribute to WHO FCTC implementation) and Strategic Priority 3 (Protecting the integrity and building on the achievements under the WHO FCTC) (World Health Organization, 2019). The strategy foregrounds the importance of situating tobacco control in wider political, economic and societal contexts and the need to work across sectors to enhance whole-of-government cooperation and coordination. Our findings suggest that within countries there exist unique contextual factors, such as the presence or absence of tobacco growing, which shape implementation as well as common factors, such as industry influence, which can inform targeted and context-informed implementation.

Limitations

A limitation of our review was its focus only on countries that had ratified the WHO FCTC by 25 October 2022 (search completion date). Countries such as Malawi or Somalia were not included in this study. However, this decision allowed us to examine countries with a longer history related to the WHO FCTC implementation. A second limitation was our focus on policy implementation post-ratification of the WHO FCTC. Important lessons can be learned from further research on policy processes leading up to the WHO FCTC ratification. Furthermore, as this was a scoping review, we did not assess study quality and potential risk of bias.

CONCLUSION

Contextual factors play an important role in policy formulation, legitimation, implementation and evaluation. Further understanding contextual factors affecting the WHO FCTC national-level implementation via dedicated research can strengthen policy efforts in countries that are at the early stages of policy formulation and for countries that are aiming to strengthen policy implementation efforts. A better understanding of context including political and interconnected economic processes can also help re-align support for countries from bodies such as the WHO FCTC Secretariat, the WHO and other regional and global actors.

AUTHORS’ CONTRIBUTIONS

Shashika Bandara and Raphael Lencucha conceptualized this project with Shashika Bandara, Raphael Lencucha, Jeffrey Drope, Matthew Hunt and Alayne Adams contributing to the designing of the study. Shashika Bandara and Raphael Lencucha conducted the initial analysis, and all authors contributed to the analysis or interpretation of data. Shashika Bandara wrote the first draft and subsequent drafts with critical input from all authors via multiple rounds of editing and adding relevant important intellectual content. All authors approved the final version to be published and have agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude and acknowledge the comprehensive support of the methods expert Genevieve Gore at McGill University Libraries.

FUNDING

This project is funded by a Canadian Institute of Health Research grant (PJT166086). Lead author also received funding from the Vanier Scholarship from the Government of Canada.

CONFLICT OF INTEREST

There are no conflicts of interest to report for any author.

DATA AVAILABILITY

The data underlying this article are available in the article and its online supplementary material.

REFERENCES