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The Westphalian idea of sovereignty in international relations has undergone recent transformation. "Shared sovereignty" through multilevel governance describes the responsibility of the European Union (EU) and its Member States in tobacco control policy. We examine how this has occurred on the EU level through directives and recommendations, accession rules for new members, tobacco control campaigns, and financial support for antitobacco nongovernmental organizations. In particular, the negotiation and ratification of the Framework Convention on Tobacco Control (FCTC) and the participation in the FCTC Conference of the Parties illustrates shared sovereignty. The EU Commission was the lead negotiator for Member States on issues over which it had jurisdiction, while individual Member States, through the EU presidency, could negotiate on issues on which authority was divided or remained with them. Shared sovereignty through multilevel governance has become the norm in the tobacco control policy area for EU members, including having one international organization negotiate within the context of another.

The Westphalian idea of sovereignty in international relations has undergone recent transformation. 'Shared sovereignty' through multilevel governance describes the responsibility of the European Union (EU) and its Member States in tobacco control policy. We examine how this has occurred on the EU level through directives and recommendations, accession rules for new members, tobacco control campaigns, and financial support for antitobacco nongovernmental organizations. In particular, the negotiation and ratification of the Framework Convention on Tobacco Control (FCTC) and the participation in the FCTC Conference of the Parties illustrates shared sovereignty. The EU Commission was the lead negotiator for Member States on issues over which it had jurisdiction, while individual Member States, through the EU presidency, could negotiate on issues on which authority was divided or remained with them. Shared sovereignty through multilevel governance has become the norm in the tobacco control policy area for EU members, including having one international organization negotiate within the context of another. Adapted from the source document.

This paper examines the historical experience of tobacco control in the last five decades and shares important lessons of public health interventions to inform current and future tobacco control programs in other countries. The paper is divided into four parts. The first part gives an overview of the political economy, principal influences and interventions in tobacco control in the United States. It stresses the importance of information shocks and the role played by grassroots organizations. The current situation of tobacco control in the United States is further discussed in the second part, with emphasis on the economic case that led to litigation, as well as the response of the industry and the States. The third part focuses on the present efforts of multilaterals like the World Bank, technical UN agencies such as the World Health Organization, in the context of the new global governance structure: the Framework Convention on Tobacco Control (FCTC). The last section discusses lessons learned and provides recommendations for comprehensive tobacco control programs. The paper suggests five major policy drivers that constitute components of a comprehensive tobacco control program: – science to inform policy, information strategies to educate consumers, advocacy to stimulate interventions, legal actions to develop regulations, and international collaboration through the FCTC. The paper concludes that while government has the responsibility for funding and implementing these activities; these can be most effective when supported by civil society.

In 1999 the World Bank published a landmark study on the economics of tobacco control, Curbing the Epidemic: Governments and the Economics of Tobacco Control (CTE), which concluded that tobacco control brings unprecedented health benefits without harming economies, threatening the transnational tobacco companies' ability to use economic arguments to dissuade governments from enacting tobacco control policies and supporting the WHO Framework Convention on Tobacco Control (FCTC). We used tobacco industry documents to analyze how tobacco companies worked to discredit CTE. They hired public relations firms, had academics critique CTE, hired consultants to produce "independent" estimates of the importance of tobacco to national economies, and worked through front groups, particularly the International Tobacco Growers' Association, to question CTE's findings. These efforts failed, and the report remains an authoritative economic analysis of global tobacco control during the ongoing FCTC negotiations. The industry's failure suggests that the World Bank should continue their analytic work on the economics of tobacco control and make tobacco control part of its development agenda.

Between 1999 and 2001, British American Tobacco, Philip Morris, and Japan Tobacco International executed Project Cerberus to develop a global voluntary regulatory regime as an alternative to the Framework Convention on Tobacco Control (FCTC). They aimed to develop a global voluntary regulatory code to be overseen by an independent audit body and to focus attention on youth smoking prevention. The International Tobacco Products Marketing Standards announced in September 2001, however, did not have the independent audit body. Although the companies did not stop the FCTC, they continue to promote the International Tobacco Products Marketing Standards youth smoking prevention as an alternative to the FCTC. Public health civil society groups should help policymakers and governments understand the importance of not working with the tobacco industry.

In the last two decades, global action to address noncommunicable diseases (NCDs) has accelerated, but policy adoption and implementation at the national level has been inadequate. This analysis examines the role of rationalities of governing, or governmentality, in national-level adoption of global recommendations. Critical discourse analysis was conducted using 49 formal institutional and organizational documents obtained through snowball sampling methodology. Text were coded using a framework of five forms of governmentality and analyzed to describe the order of discourse which has emerged within the global NCD policy domain. The dominant political rationality used to frame NCDs is rooted in risk governmentality. Recommendations for tobacco control and prevention of harmful alcohol use rely on a governmentality of police mixed with discipline. The promotion of physical activity relies heavily on disciplinary governmentality, and the prevention of unhealthy diet mixed disciplinary measures, discipline, and neoliberal governmentalities. To translate global NCD prevention and control strategies to national action, acceptability for the political rationalities embodied in policy options must be nurtured as new norms, procedures, and institutions appropriate to the political rationalities of specific interventions are developed.

In the last two decades, global action to address noncommunicable diseases (NCDs) has accelerated, but policy adoption and implementation at the national level has been inadequate. This analysis examines the role of rationalities of governing, or governmentality, in national-level adoption of global recommendations. Critical discourse analysis was conducted using 49 formal institutional and organizational documents obtained through snowball sampling methodology. Text were coded using a framework of five forms of governmentality and analyzed to describe the order of discourse which has emerged within the global NCD policy domain. The dominant political rationality used to frame NCDs is rooted in risk governmentality. Recommendations for tobacco control and prevention of harmful alcohol use rely on a governmentality of police mixed with discipline. The promotion of physical activity relies heavily on disciplinary governmentality, and the prevention of unhealthy diet mixed disciplinary measures, discipline, and neoliberal governmentalities. To translate global NCD prevention and control strategies to national action, acceptability for the political rationalities embodied in policy options must be nurtured as new norms, procedures, and institutions appropriate to the political rationalities of specific interventions are developed.

In 2007, although Tennessee was (and still is) the third largest tobacco¬producing state, it enacted the Non¬Smoker Protection Act (NSPA), making most enclosed public and workplaces, and restaurants 100% smoke-free. This study triangulates archival documents with interviews, legislative debates and quantitative data for a stakeholder analysis of why and how the diverse interests in the state collaborated to develop the policy and identifies areas and opportunities for improvement. The study utilizes the policy cycle and stages of policy development approach and three public policy models – garbage can or multiple streams, policy networks, and socio¬economic influences – to give us understanding of the phases of the development of the NSPA – agenda-setting, legislative development, and implementation. While the dominant thesis for the origin of this smoke¬free policy (SFP) was government¬centered, the activities of non¬governmental actors, such as efforts by students of University of Tennessee in Knoxville to have smoke¬free domitories and that of Campaign for Healthy and Responsible Tennessee (CHART) to repeal preemption (nongovernmental¬centered thesis), and societal changes (bubble¬up thesis) contributed to its emergence. The SFP entered the state's policy agenda when the problem of tobacco use in the state (health consequences and costs) and policy solutions (including SFP) became coupled with favorable political circumstances involving Governor Phil Bredesen's unexpected announcement of support for a statewide SFP during smoke¬free state buildings bill signing ceremony in June 2006. This announcement created a window of opportunity for SFP change, which was seized by a change agent in the state, CHART. In February 2007, the Governor included SFP in the administration's legislative package for the 105th Legislative Session. Additionally, SFP bills were sponsored in both houses of the Legislature to make SFP a priority item on the state's policy agenda. The development of the NSPA was facilitated by factors, such as the administration's continuous support for the SFP, activities of CHART, public support for the SFP, U¬turn in the position of Tennessee Restaurant Association (now Tennessee Hospitality Association) to support 100% SFP and limited opposition from tobacco interests in the state. Although implementation of the NSPA has generally proceeded smoothly, about half of the stakeholders prefer that the exemptions are repealed, particularly those for age¬restricted venues, non¬enclosed areas of public places and private businesses with three or fewer employees. This study suggests that there is high level of knowledge on tobacco use (the problem) and control (policy solutions) in policy circles and the key remaining factors for policy change are favorable political environment and a change agent. The development of the NSPA suggests that proponents for policy change should know and understand their policy and political environment and be alert for any change that will facilitate the development of an SFP.

Abstract Background The tobacco industry has globalized and tobacco use continues to increase in low- and middle-income countries. Yet, the data and research to inform policy initiatives for addressing this phenomenon is sparse. This study aims to estimate the prevalence of adult tobacco use in 17 Sub-Saharan Africa (SSA) countries, and to identify key factors associated with adult tobacco consumption choices (smoked, smokeless tobacco and dual use) in Madagascar. Methods We used Demographic Health Survey for estimating tobacco use prevalence among adults in SSA. A multinomial logistic regression model was used to identify key determinants of adult tobacco consumption choices in Madagascar. Results While differences in tobacco use exist in SSA, Madagascar has exceptionally higher prevalence rates (48.9% of males; 10.3% of females). The regression analyses showed complexity of tobacco use in Madagascar and identified age, education, wealth, employment, marriage, religion and place of residence as factors significantly associated with the choice of tobacco use among males, while age, wealth, and employment were significantly associated with that of females. The effects, however, differ across the three choices of tobacco use compared to non-use. Conclusions Tobacco use in Madagascar was higher than the other 16 SSA countries. Although the government continues to enact policies to address the problem, there is a need for effective implementation and enforcement. There is also the need for health education to modify social norms and denormalize tobacco use.

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee—a high-smoking, low-income region. During 2015–2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee—a high-smoking, low-income region. During 2015–2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants' aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Healthcare providers' (HCPs) recommendations for the Human Papillomavirus (HPV) vaccine are likely to increase the vaccination uptake. However, little is known about Ghanaian HCPs' general practices regarding HPV vaccination. We used Multi-Theory Model (MTM) constructs (i.e. participatory dialogue, behavioral confidence, environment, social and emotional transformation) to examine Ghanaian HCPs' attitudes towards HPV vaccination and their vaccination recommendation practices. Methods We conducted three, 60-minute focus group discussions (FGDs) with HCP in the secondlargest government hospital in Ghana. Sixteen semi-structured open-ended questions based on MTM constructs were used to guide the FGDs. We explored HCPs' general knowledge about HPV, vaccination recommendation behavior, physical environment, and sociocultural factors associated with the HPV vaccination. Data from the FGDs were transcribed and thematically coded using NVivo software. Results The sample of (n = 29) HCPs consisting of males (n = 15) and females (n = 14) between the ages of 29 and 42 years participated in the FGDs. Our analyses showed that HCPs (a) rarely offered HPV vaccination recommendations, (b) showed varied understanding about who should be vaccinated regarding age eligibility, gender, and infection status. Perceived barriers to HPV vaccination include (a) low urgency for vaccination education due to competing priorities such as malaria and HIV/AIDS; (b) lack of data on HPV vaccination; (c) lack of awareness about the vaccine safety and efficacy; (c) lack of HPV vaccine accessibility and (d) stigma, misconceptions and religious objections. HCPs expressed that their motivation for counseling their clients about HPV vaccination would be increased by having more knowledge about the vaccine's efficacy and safety, and the involvement of the parents, chiefs, churches, and opinion leaders in the vaccination programs. Conclusion The study's findings underscore the need for a comprehensive HPV vaccination education for HCPs in Ghana. Future HPV vaccination education programs should include information about the efficacy of the vaccine and effective vaccination messages to help mitigate HPV vaccine-related stigma.