'That is a Ministry of Health thing':Article 5.3 implementation in Uganda and the challenge of whole-of-government accountability

INTRODUCTION: While Uganda has made legislative progress towards implementing Article 5.3 of the WHO Framework Convention on Tobacco Control (FCTC), ongoing challenges in minimising tobacco industry interference have not been adequately explored. This analysis focuses on understanding difficulties in managing industry engagement across government ministries and in developing effective whole-of-government accountability for tobacco control. METHODS: Interviews with Uganda government officials within the health sector and beyond, including in Ministries of Trade, Agriculture and Revenue. RESULTS: The findings indicate substantial variations in awareness of Article 5.3, its norm and practices across government sectors. The data suggest ambiguity and uncertainty about accountability for Article 5.3 implementation, with policy makers in departments beyond health often uncertain about obligations under the FCTC. Second, we highlight how responsibility for Article 5.3 implementation and the obligations incurred are widely seen as restricted to the Ministry of Health. Third, competing mandates and perceived difficulties in reconciling health goals with economic growth are shown to impact on accountability for tobacco control. Yet, importantly, the data also demonstrate enthusiasm in some unexpected parts of government for actively engaging with Article 5.3 and for promoting greater intersectoral coordination. CONCLUSION: This paper demonstrates the intrinsic challenges of developing whole-of-government approaches, highlighting considerable uncertainty and ambiguity among decision makers in Uganda about tobacco control governance. The analysis points to the potential for Uganda’s national coordinating mechanism to help reconcile competing expectations and demonstrate the importance of Article 5.3 beyond health actors

HIV health care providers’ perspectives on smoking behavior among PLHIV and smoking cessation service provision in HIV clinics in Uganda

Introduction: Integration of smoking cessation interventions into HIV care can play a crucial role in reducing the growing burden of disease due to smoking among people living with HIV (PLHIV). However, there is a dearth of information on HIV care providers’ perspectives towards integrating smoking cessation interventions into HIV care programs. We explored HIV health care providers’ perceptions on the smoking behaviour among PLHIV, and the provision of smoking cessation services to PLHIV who smoke within HIV care services in Uganda. Methods: Semi structured face-to-face qualitative interviews were conducted with 12 HIV care providers between October and November 2019. Data were collected on perceptions on smoking among HIV-positive patients enrolled in HIV care, support provided to PLHIV who smoke to quit and integrating smoking cessation services into HIV care programs. Data were analysed deductively following a thematic framework approach. Results: Findings show that: a); HIV care providers in HIV clinics had low knowledge on the prevalence and magnitude of smoking among PLHIV who attended the clinics b) HIV care providers did not routinely screen HIV-positive patients for smoking and offered sub-optimal smoking cessation services; c) HIV care providers had a positive attitude towards integration of tobacco smoking cessation services into HIV care programs but called for support in form of guidelines, capacity building and strengthening of data collection and use as part of the integration process. Conclusion: Our study shows that HIV care providers did not routinely screen for tobacco use among PLHIV and offered suboptimal cessation support to smoking patients but they have a positive attitude towards the integration of tobacco smoking into HIV care programs. These findings suggest a favourable ground for integrating tobacco smoking cessation interventions to into HIV care programmes

Tobacco use and cessation in the context of ART adherence : insights from a qualitative study in HIV clinics in Uganda

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers

Tobacco smoking and associated factors among people living with HIV in Uganda

Introduction: This study aimed to assess smoking patterns, behaviours and associated factors among people living with HIV (PLWH) in Uganda. Methods: A cross-sectional survey was conducted among adults in HIV care in Uganda. Descriptive statistics were used to describe smoking patterns and behaviours. Logistic regression was used to identify factors associated with current smoking status. Results: We recruited 777 participants between October and November 2019: 387 (49.8%) current smokers and 390 (50.2%) non-smokers. 60.9% were males, and the mean age was 40.5 (SD 10.7) years. In multivariate logistic regression, the following increased the odds of being a current smoker: being male (OR 6.60 (95%CI= 4.34 to 10.04)), having at least two smokers among five closest friends (OR 3.97 (95%CI=2.08 to 7.59)), living in smoking-permitted households (OR 5.83 (95%CI= 3.32 to 10.23)), alcohol use (OR 3.96 (95%CI= 2.34 to 6.71)), a higher perceived stress score (OR 2.23 (95%CI= 1.50 to 3.34)), and higher health-related quality of life (OR 5.25 (95%CI= 1.18 to 23.35)). Among smokers, the mean Fagerstrom Test for Nicotine Dependence score was 3.0 (SD 1.9), and 52.5% were making plans to quit. Self-efficacy to resist smoking and knowledge of the impact of smoking on PLWH’s health were low. Conclusions: Being male, having at least two smokers among five closest friends, living in smoking-permitted households, alcohol use, higher perceived stress scores and higher health-related quality of life were associated with being a current smoker. Smokers had low to moderate nicotine dependence, high willingness to quit, and low self-efficacy

Practices related to tobacco sale, promotion and protection from tobacco smoke exposure in restaurants and bars in Kampala before implementation of the Uganda tobacco control Act 2015

Introduction The Word Health Organization’s Framework Convention on Tobacco Control calls on parties to implement evidenced-based tobacco control policies, which includes Article 8 (protect the public from exposure to tobacco smoke), and Article 13 (tobacco advertising, promotion and sponsorship (TAPS)). In 2015, Uganda passed the Tobacco Control Act 2015 which includes a comprehensive ban on smoking in all public places and on all forms of TAPS. Prior to implementation, we sought to assess practices related to protection of the public from tobacco smoke exposure, limiting access to tobacco products and TAPS in restaurants and bars in Kampala City to inform implementation of the new law. Material and Methods This was a cross-sectional study that used an observational checklist to guide observations. Assessments were: whether an establishment allows for tobacco products to be smoked on premises, offer of tobacco products for sale, observation of tobacco products for sale, tobacco advertising posters, illuminated tobacco advertisements, tobacco promotional items, presence of designated smoking zones, no-smoking signs and posters, and observation of indoor smoking. Managers of establishments were also asked whether they conducted tobacco product sales promotions within establishments. Data were collected in May 2016, immediately prior to implementation of the smoke-free and TAPS laws. Results Of the 218 establishments in the study, 17% (n = 37) had no-smoking signs, 50% (n = 108) allowed for tobacco products to be smoked on premises of which, 63% (n = 68) had designated smoking zones. Among the respondents in the study, 33.3% (n = 72) reported having tobacco products available for sale of which 73.6% (n = 53) had manufactured cigarettes as the available tobacco products. Eleven percent (n = 24) of respondents said they conducted tobacco promotion within their establishment while 7.9% (n = 17) had promotional items given to them by tobacco companies. Conclusions Hospitality establishments in Kampala are not protecting the public from tobacco smoke exposure nor adequately limiting access to tobacco products. Effective dissemination of the Tobacco Control Act 2015 is important in ensuring that owners of public places are aware of their responsibility of complying with critical tobacco control laws. This would also likely increase self-enforcement among owners of hospitality establishments and public patrons of the no-smoking restrictions

International collaboration to build tobacco control capacity: a case study of KOMPLY from the World Heart Federation Emerging Leaders program

Background and challenges to implementation Article 22 of the Framework Convention on Tobacco Control calls for collaboration among the Parties and international organizations to facilitate the development, transfer and acquisition of knowledge, skills, capacity and expertise related to tobacco control. International collaborations are especially important to help counter the tobacco epidemic in low and middle-income countries and will also contribute to UN Sustainable Development Goals. We will summarise the World Heart Federation (WHF) Emerging Leaders program, using the case study of the KOMPLY collaboration which focused on evaluating and supporting compliance with Uganda's newly implemented smoke-free legislation. Intervention or response As part of WHF's goal to reduce cardiovascular disease by 25% by 2025, an Emerging Leaders program was initiated of which the 2016 focus was tobacco control. Twenty-five Emerging Leaders from across the globe were selected and attended a WHF think-tank. Participants received education, training, mentoring and the opportunity to apply for seed funding, to facilitate leadership and the development of a new collaborative tobacco control project. Results and lessons learnt In the 18 months following the think-tank, the KOMPLY team collected evidence that showed poor compliance with the smoke-free legislation in Ugandan hospitality venues (e.g. designated smoking areas were present, no-smoking signage was absent, hazardous levels of tobacco particulate matter in venues that allowed smoking). This evidence is being used by the Ugandan government to defend the 2015 Tobacco Control Act in response to litigation by British American Tobacco. Outputs produced include a factsheet and technical report for Ugandan stakeholders, academic articles and conference presentations. Team members established working relationships with individuals from key international tobacco control organisations, developed academic outputs, acquired new skills and opportunities for further professional development. Conclusions and key recommendations Initiatives such as WHF's Emerging Leaders program can make a substantial contribution to building capacity for tobacco control, through fostering international collaborations to increase leadership, research and advocacy efforts in LMICs

Implementation of 100% smoke-free law in Uganda: a qualitative study exploring civil society’s perspective

Abstract Background In 2016, Uganda became one of few sub-Saharan African countries to implement comprehensive national smoke-free legislation. Since the World Health Organisation recommends Civil Society Organisation’s (CSO) involvement to support compliance with smoke-free laws, we explored CSOs’ perceptions of law implementation in Kampala, Uganda, and the challenges and opportunities for achieving compliance. Since hospitality workers tend to have the greatest level of exposure to second-hand smoke, we focussed on implementation in respect to hospitality venues (bars/pubs and restaurants). Methods In August 2016, three months after law implementation, we invited key Kampala-based CSOs to participate in face-to-face semi-structured interviews. Interviews probed participants’ perceptions about law implementation, barriers impeding compliance, opportunities to enhance compliance, and the role of CSOs in supporting law implementation. Interviews were recorded and transcribed. Qualitative content analysis was conducted using the interview transcripts. Results Fourteen individuals, comprising mainly senior managers from CSOs, participated and reported poor compliance with the smoke-free law in hospitality venues. Respondents noted that contributing factors included low awareness of the law amongst the general public and hospitality staff, limited implementation activities due to scarce resources and lack of coordinated enforcement. Opportunities for improving compliance included capacity building for enforcement agency staff, routine monitoring, rigorous enactment of penalties, and education about the smoke-free law aimed at hospitality venue staff and the general public. Allegations of tobacco industry misinformation were said to have undermined compliance. Civil Society Organisations saw their role as supporting law implementation through education, stakeholder engagement, and evidence-based advocacy. Conclusions This study suggests that the process of smoke-free law implementation in Uganda has not aligned with World Health Organisation (WHO) guidelines for implementing smoke-free laws, and highlights that low-income countries may need additional support to enable them to effectively plan for policy implementation and resist industry interference