Nicotine & Tobacco Research Volume 9, Supplement 3 (November 2007) S447–S457

Review

Tobacco control in developing countries: Tanzania,

Nepal, China, and Thailand as examples

Steve Sussman, Pallav Pokhrel, David Black, Matthew Kohrman,

Stephen Hamann, Prakit Vateesatokit, Stephen E. D. Nsimba

Received 7 June 2006; accepted 11 April 2007

This paper illustrates case studies of four developing countries and compares them as to relative advancement in
tobacco control as prescribed by the Framework Convention on Tobacco Control. Tobacco-control efforts first
seem to involve assessment of tobacco use prevalence and passage of tobacco-control legislation (e.g., warning
labels). Tanzania, Nepal, and China serve as examples. Eventually, an integrated tobacco-control stance that
demonstrates several cycles of tobacco-control activities occurs, as is shown in Thailand. Through these case
studies, one can achieve a sense of the direction of progress in tobacco control in developing countries.

Introduction low prices. These tobacco companies seek to team up

More than 1 billion people worldwide smoke. If
current trends continue, 8.4 million smokers are
estimated to die annually of smoking-related deaths
by the year 2020 (Kaufman & Yach, 2000). Partly in
response to the expansion of the World Trade
Organization’s Global Agreement on Tariffs and
Trade (GATT) to agricultural products in 1994,
which opened up international trade as a nondiscri-
minatory enterprise, tobacco industries now are
operating as transnational organizations that have
been able to provide tobacco products at relatively
Steve Sussman, Ph.D., Pallav Pokhrel, B.A., David Black, M.P.H.,
Department of Preventive Medicine, Institute for Health Promotion
and Disease Prevention Research, University of Southern California,
Alhambra, CA; Matthew Kohrman, Ph.D., Department of
Anthropology, Stanford University; Prakit Vateesatokit, M.D.,
Ramathibodi Medical School, Mahidol University, Bangkok,
Thailand; Stephen Hamann, Ed.D., Consultant, International
Affairs, Thai Health Promotion Foundation, Bangkok, Thailand;
Stephen E. D. Nsimba, Ph.D., Muhimbili University College of Health
Sciences (MUCHS), Department of Clinical Pharmacology, Dar Es
Salaam, Tanzania.
Correspondence: Steve Sussman, Ph.D., Preventive Medicine and
Psychology, Institute for Health Promotion and Disease Prevention
Research, University of Southern California, 1000 S. Fremont Avenue,
Unit 8, Building A-5, Suite 5228, Alhambra, CA 91803-4737, USA.
Tel: +1 (626) 457-6635; Fax: +1 (626) 457-4012; E-mail: ssussma@
usc.edu
with local growers, provide incentives to local
storeowners, and market themes of sophistication,
wealth, or attractiveness that promote a global
cosmopolitan cultural demand for tobacco products
(Chaloupka & Nair, 2000). Tobacco industry docu-
ments indicate a desire for global penetration in
markets throughout Europe, Asia, and Africa (Yach
& Bettcher, 2000). From 1993 to 1996, exports of
tobacco products increased 42%, coupled by a 5%
increase in international consumption (Chaloupka &
Nair, 2000). Trade liberalization has been associated
with increased cigarette smoking, particularly in low-
to-middle income countries (Taylor, Chalouka,
Guindon, & Corbett, 2000).
In May of 2003, the member countries of the
World Health Organization (WHO) adopted the
Framework Convention on Tobacco Control
(FCTC). The FCTC is an internationally based
agreement that would commit countries to adopt
strong tobacco-control policies. It entered into force
on February 27, 2005. A total of 168 countries have
signed the treaty, and currently 144 have become
parties to the treaty (as of February 6, 2007). To
become binding agreements, countries must become
parties to the treaty (i.e., ratify the agreement). The
FCTC contains no punitive provisions for states that

ISSN 1462-2203 print/ISSN 1469-994X online # 2007 Society for Research on Nicotine and Tobacco
DOI: 10.1080/14622200701587078
S448 TOBACCO CONTROL IN DEVELOPING COUNTRIES
ignore their treaty obligations; instead, the FCTC
adopts an institutional mechanism of public mon-
itoring of compliance. The FCTC has raised the
profile of tobacco control internationally to a level
not previously seen. The FCTC contains 38 articles,
which lay out the treaty provisions (WHO, 2003).
Key provisions are shown in Table 1.
The present article provides case studies of
tobacco-control efforts in regions of Asia and
Africa, illustrating national level compliance in
developing countries. We use the FCTC regulations
as an organizing guide to assessing level of tobacco
control. The four developing country case studies
involved in the present study—Tanzania, Nepal,
China, and Thailand—came together as presenta-
tions at the Second East–West Conference on
Tobacco and Alcohol Use organized by University
of Southern California’s Institute for Health
Promotion & Disease Prevention Research (IPR) in
April 2005.
Table 1. Core WHO FCTC provisions against tobacco use.
Exchange of information and technology
Article Measure
Demand reduction, and ETS reduction, and cessation
6 Price and tax
7 Non-price
8 Protection from exposure
9 Regulation of the contents
10 Regulation of tobacco
product disclosures
11 Packaging and labeling
12 Education, communication,
training, and awareness
13 Advertising, promotion, and
sponsorship
14 Cessation and treatment of
dependence
Supply reduction
15 Control of illicit trade
16 Preventing sales to and by minors
17 Supporting economically viable
alternative activities
Note: Articles 6–14 contain the core demand and exposure to ETS reduction provisions in the WHO FCTC treaty. Articles 15–17 and
articles 20–22 lay out core supply reduction provisions and ways to increase the exchange of technology and information, respectively.
We first introduce each of the four countries in
terms of smoking prevalence and the extent of their
tobacco-based economy. Next, we discuss the coun-
try-specific tobacco-control efforts. The core obliga-
tions required by WHO FCTC concentrate on
reducing demand and supply of tobacco in society,
reducing exposure to environmental tobacco smoke
(ETS), and supporting tobacco use cessation (WHO,
2003). Some of the authoritative review publications
on tobacco-control legislation, policies, and inter-
ventions, associated directly or indirectly with
organizations such as National Cancer Institute
(NCI) (e.g., Novotny, Romano, Davis, & Mills,
1992) and Centers for Disease Control and
Prevention (CDC) (e.g., Hopkins et al., 2001), were
consulted as well. However, the FCTC is an
internationally implemented set of policies, whereas
the others, while influencing development of the
FCTC regulations, have been applied primarily to
the United States.
Objective
Implement tax and price policies on tobacco products to
reduce tobacco consumption.
Adopt legislative, executive, administrative or other
measures to implement articles 8–13.
Protection from exposure to tobacco smoke in indoor
workplaces, public transport, indoor public places and
other public places.
Test and measure the contents and emissions of tobacco
products, and regulate these contents and emissions.
Require manufacturers and importers of tobacco products
to disclose to government authorities the contents and
emissions of tobacco products.
Ensure that tobacco product packaging and labeling carry
health warning and do not promote tobacco use; remove
misleading terms such as ‘‘low tar’’, ‘‘light’’, ‘‘ultra-light’’, or
‘‘mild’’ from product packaging; health warnings should
contain 50% or more (at least 30%) of the principle display
area of the packaging.
Promote public awareness of tobacco control issues
through effective communication, training, and education;
involve health workers, community workers, social workers,
media professionals, and educators in awareness campaigns.
Ban advertisement, promotion, and sponsorship that would
encourage tobacco use and/or cause misleading impressions
about tobacco’s characteristics, health effects, and hazards.
Promote cessation of tobacco use and treatment of
dependence based on scientific evidence, taking into
account national priorities.
Enforce strong national laws against smuggling, illicit
manufacturing, and counterfeiting of tobacco products.
Require sellers of tobacco to place clear signs in the shops
about prohibition of tobacco sales to minors, to ask for age
verification if in doubt; ban sales in places accessible to
minors (e.g., close to school); prohibit the manufacture and
sale of sweets, snacks, toys in the form of tobacco products.
Promote economically viable alternatives for tobacco workers,
growers, and, if necessary, individual sellers.

We completed searches in PsychINFO (1970 to
July 1, 2006) and Ovid Medline (1950 to July 1,
2006), pairing each country’s name with ‘‘tobacco.’’
All relevant articles are included in this review, and
we examined both English and native-country
language articles. In order to systematize the
evaluation of the four countries’ tobacco-control
efforts and compare the breadths of their tobacco-
control policies and programs, we counted the
number of control strategies that each country has
been able to implement (number of positives) and
the number of strategies that it has not (number of
negatives) (Table 2). We followed this method,
which is similar to meta-synthesis or meta-ethno-
graphy, as if each country-specific case study were
assumed to be an ethnographic case study (Noblit &
Hare, 1988; Davies, 2000). We assigned a positive
(+) to a country for a tactic only when the tactic was
shown by published literature to be enacted and
purportedly used in the country. A negative count
(2) was given a country for a tactic which the
country did not use at all. Author consensus was
established and provided in Table 2. This consensus
was labeled as the ‘‘standard.’’ Next, an article
review synthesis from each country was provided to
four graduate student assistants. These included 1
Nepalese male, 1 Chinese male, 1 Taiwanese female,
and 1 U.S. female (whose parents were from Mexico
and Vietnam). The raters varied in age from 25 to
29 years old. Tobacco-control strategies were rated
on the criteria indicated in Table 2. Each rater’s
overall percentage agreement with the standard
across 11 categories and across 4 countries was
calculated and then averaged across the raters.
Interrater agreement with the standard was an
average of 84%, suggesting fairly high agreement
with the standard.
Tobacco control in The United Republic of Tanzania
Smoking prevalence
The available data on smoking prevalence in
Tanzania are based on regional studies carried out
in or around urban areas (Arusha, Dar es Salaam,
Morogoro, and Moshi). These studies indicate that
1%–5% of women and 21%–27% of men are current
smokers in Tanzania (Arya & Bennett, 1997; Bovet
et al., 2002; Corrao, Guindon, Sharma, & Shokoohi,
2000; Lore & Lwenya, 1998; Jagoe, Edwards,
Mugusi, Whiting, & Unwin, 2002; Keneth, 2005;
Mackay, Eriksen, & Shafey, 2006; Maher & Mvula,
1996; Ministry of Health and AMMP Team, 1997;
Shafey, Dolwick, & Guindon, 2003). More up-to-
date smoking prevalence data for adults, based on a
representative national survey, which includes rural
areas, is lacking for Tanzania.
NICOTINE & TOBACCO RESEARCH S449
Likewise, only urban regional data is available to
estimate the percentage of persons exposed to second-
hand smoke in Tanzania (Mackay et al., 2006).
According to the Global Youth Tobacco Survey,
19%–31% of students reported living in homes where
other people smoked in their presence, and 26%–38%
reported that they were used to being exposed to
tobacco smoke in public places (Kilimanjaro region
[cities of Arusha and Moshi] and Dar es Salaam)
(GYTS—Arusha, 2003; GYTS—Dar Es Salaam,
2003; GUTS— Kilimanjaro, 2003).
Tobacco-based economy
About 0.08% of Tanzania’s land (about 34,000
hectares) is allocated for growing tobacco (Mackey
et al., 2006). Tanzania is one of the biggest producers
of tobacco in Africa, ranked third after Zimbawe and
Malawi (Hammond, 1997). Tobacco is one of the
cash crops that help boost the country’s foreign
exchange, contributing about 60% of the Gross
Domestic Product (GDP) (Corrao et al., 2000;
Jacobs, Gale, Caperhart, Zhang, & Jha, 2000).
Tanzania’s tobacco output increased seven-fold
between 1975 and 1998 and continues to grow
(Corrao et al., 2000; Jacobs et al., 2000). Still, import
of manufactured cigarettes exceeds export by 4
million sticks (Shafey et al., 2003).
Attempts to reduce demand and supply of tobacco
Price-based measure. The total percent tax assessed
is 47.2% (average excise tax plus sales tax; Shafey
et al., 2003). No available evidence suggests that
Tanzania dedicates any portion this tax to tobacco
control and health promotion (Mackay et al., 2006).
Nonprice measures. Selling tobacco products to
minors (under 18) and selling them in locations near
schools are legally prohibited in Tanzania (Shafey
et al., 2003). However, age verification for sales is not
legally required. In the Global Youth Tobacco
Survey (2003), 13%–23% of 6th and 7th grade
smokers from the cities of Arusha (N52,018),
Moshi (N52,323), and Dar Es Salaam (N51,947)
reported that they bought their cigarettes in stores
and were not refused purchases because of their age.
The law requires tobacco product manufacturers
to obtain licenses from the Ministry of Community
Development and to include health warnings on
product packages. The health warnings cover only
6% of the face of a pack. There is a ban on
advertising in radio, television, and domestic print
media; however, billboard advertising of tobacco
products, point-of-sale advertising, and event spon-
sorships are still permitted (Mackay et al., 2006;
Shafey et al., 2003). In fact, British and American
 S450
TOBACCO CONTROL IN DEVELOPING COUNTRIES
Table 2. Number of standard tobacco control strategies used and not used by Tanzania, Nepal, China, and Thailand.

Country

Anti-tobacco strategy Tanzania Nepal China Thailand

1
1. Assessment of prevalence
2. Tax as a % of cigarette price (WHO
FCTC recommended: 66% of retail cost)1
3. Warning labels on package (FCTC
standard530%, FCTC recommended550%)2
4. Smoking in public locations2,3
5. Advertisements of tobacco products2,3
3
6. Selling cigarette to minors
7. Manufacturing licensure required3
8. Tobacco use cessation efforts2
9. Encourage activism efforts such as public
protests against tobacco industry1
10. Sign FCTC1
11. Ratify FCTC4
Total of +s of 11
+ (regional) + (nationally representative) + (nationally representative) + (nationally representative)
2 (47%) 2 (25%–50%)a 2 (40%) + (60%)
2(6%) 2(4%) +(30%) +(50%)
+ + + +
+ (partial ban)b + (partial ban) + (partial ban) + (comprehensive ban)c
+ (banned but no age-verification) 2 + (banned but no age-verification) + (banned but no age-verification
in rural regions)
+ + + +
2 (aside from World No + + +
Tobacco Day)
2 2 2 +
+ + + +
+ (April 30,2007) + (November 7, 2006) + (October 11, 2005) + (November 8, 2004)
7 7 9 10

Note. 2, anti-tobacco tactic not used; +, anti-tobacco tactic used at least weakly. From left to right columns prevalence of tobacco use among males is 23.0%, 48.4%, 63.0%, and 37.2%, respectively,
and is 1.3%, 28.7%, 3.8%, and 2.1% among females, respectively. 1Multiple sources, see text. 2Source: Mackay et al., 2006. 3Source: Shafey et al., 2003. 4Source: World Health Organization, 2007.
Note that it was while this paper was being reviewed and revised that Nepal and Tanzania ratified the FCTC. Even though all four countries have now ratified the FCTC, the staggered dates help
illustrate the ongoing and dynamic process of the development of tobacco control. aExcise tax varies according to cigarette brand and length of cigarette stick. bPartial ban: ban on radio, television and
domestic print media only. cComprehensive ban: complete advertising ban including billboards, point-of sale advertising and event sponsorship.

Tobacco (BAT) recently donated TSh90 million
(approximately US$72,000 as of October 2006) to
the government of Tanzania by way of sponsoring
the 8th East African Community (EAC) Jua Kali
exhibition, which was held in Dar es Salaam in
December 2006 (‘‘East Africa: Dar to Host ‘Jua Kali’
Exhibition,’’ 2006).
Anti-tobacco educational campaigns in Tanzania
have had considerable effects on spreading anti-
tobacco knowledge, especially among youth. Among
city youth, 59%–71% reported that during the past
year they had been taught about the dangers of
smoking in class. In addition, 37%–39% said that in
the past year they had discussed in class the reasons
why people their age smoke (GYTS—Nepal, 2003).
The GTYS also showed that 77%–85% students had
seen anti-smoking media messages in the past 30 days.
Attempts to control exposure to ETS
Smoking in Tanzania is prohibited in health care
facilities, and the law requires restaurants to provide
no-smoking sections as an option to customers (Shafey
et al., 2003). There are no laws against smoking in
public places, such as government worksites, educa-
tional facilities, and public transportation areas.
Tobacco use cessation efforts
Aside from annual participation in World No
Tobacco Day, there is no available evidence suggest-
ing that encouraging tobacco use cessation programs
has gained the attention of public health policy
makers in Tanzania (Mackey et al., 2006).
FCTC status and summary
Tanzania signed the FCTC on January 27, 2004, and
ratified it on April 30, 2007 (WHO, 2007). It appears
that 7 of 11 key policies have been enacted, but more
prevalence data are needed, and some enforcement
appears to be lacking.
Tobacco control in Nepal
Smoking prevalence
According to a nationally representative survey, daily
smoking prevalence in Nepal was 48.4% and 28.7%
for males and females (15 years and older) respectively
(Karki, Pande, & Pant, 2003). In addition to cigarette
smoking, beedi smoking (indigenous cigarettes made
by rolling tobacco in the leaves of the tree Diospyros
melanoxylon) is also common in Nepal. Beedi smoking
is more prevalent in Nepal than the smoking of
manufactured cigarettes: Per capita beedi consump-
tion for individuals 15 and older was estimated at 690
NICOTINE & TOBACCO RESEARCH S451
sticks in 1990, compared with 580 sticks for manu-
factured cigarettes (WHO Global Status Report—
Nepal, 1997). No updated statistics comparing beedi
smoking with cigarette smoking are available. It is
estimated that 20%–44% of youth in Nepal live in
homes where others smoke in their presence (GYTS—
Nepal, 2003; Mackay et al., 2006), and 56.4% reported
spending time around smokers outside their home
(GYTS—Nepal, 2003).
Tobacco-based economy
About 0.3% of Nepal’s land (about 3,398 hectares) is
devoted to growing tobacco (Mackey et al., 2006).
Tobacco is considered one of Nepal’s cash crops. The
quantity of cigarettes Nepal exports is not known;
however, its import of cigarettes in 2000 amounted to
90 millions sticks (Shafey et al., 2003). According to a
World Bank estimate (2001), taxes from the cigarette
industry contributed about 7% of the country’s total
government revenue.
Attempts to control demand and supply of tobacco
Price-based measures. In 2002 and 2003, the total tax
as percent retail price per pack of cigarettes
amounted to approximately 25% for imported
brands and ranged from 38% to 50% for the popular
domestic brands (Karki et al., 2003; Mackay et al.,
2006; combination of excise tax, health or smoking
tax, and 10% value-added tax). Although the revenue
from the health tax is being used successfully on
public health purposes, such as sponsoring anti-
tobacco campaigns, funding public health-oriented
nongovernmental organizations (NGOs), and run-
ning a cancer hospital (WHO Global Status
Report—Nepal, 1997; Karki et al., 2003; Magar &
Ghimire, 2004), the tax amount has remained fixed
for over more than a decade now while money
required for medical care has inflated.
Nonprice measures. In June 2006, the Nepalese
Supreme Court passed a verdict banning advertise-
ment of tobacco products (http://www.elaw.org/
news/advocate/default.asp?article53155). However,
anecdotal evidence suggests that this law has only
been partially implemented so far. In 1992, the
Ministry of Health created a National Anti-Tobacco
Committee in collaboration with various NGOs.
Nepal’s provisions for tobacco control include
regulation of label designs on packaging of tobacco
products and requiring tobacco manufacturers to
include health warnings and health-relevant messages
on packages (Shafey et al., 2003). In practice,
however, although all of the manufactured cigarette
packets contain health warnings (about 4% of the
size of the pack face), because of the presence of
S452 TOBACCO CONTROL IN DEVELOPING COUNTRIES
many unregistered and unregulated tobacco-related
cottage industries (Magar & Ghimire, 2004), it is
common for beedis to lack any kind of warning label.
Local NGOs and medical organizations, in colla-
boration with the Ministry of Health, have been
involved in providing anti-tobacco health education
at the school level through lectures and talk shows
and at the community level through radio, news-
paper, posters, and pamphlets (WHO Global Status
Report—Nepal, 1997); 90.6% of youth respondents
reported familiarity with anti-smoking media mes-
sages; 77.7% said they had been taught about the
dangers of tobacco use in the past year; and 55%
reported discussing, in class, the negative conse-
quences of tobacco use in the past year (GYTS—
Nepal, 2003). In addition, two notable organizations,
B.P. Koirala Medical College and Nepal Cancer
Relief Society, are engaged in promoting anti-
tobacco activism (UICC, 2005).
Attempts to control exposure to ETS
People are still largely unaware of the harmful effects
of passive smoking in the country (Karki et al.,
2003). Currently, it is illegal to smoke in Nepal
within government buildings, private worksites,
educational facilities, health care facilities, air flights,
and public transportation.
Tobacco use cessation efforts
Nepal has been an annual participant of World No
Tobacco Day and Quit-and-Win, the WHO-supported
international smoking cessation contest for adults
originally designed in Finland (Mackay et al., 2006).
FCTC status and summary
Nepal signed the FCTC on December 3, 2003, and
ratified the treaty on November 7, 2006 (WHO,
2007). It appears that 7 of 11 key policies have been
enacted and that national prevalence data have been
collected, but some enforcement appears lacking.
Tobacco control in China
Smoking prevalence
Smoking prevalence in China varies from 53% to
67% for men and 1% to 4% for women (Chinese
Academy of Preventive Medicine, 1997; Chinese
Association on Smoking and Health, 2004; Mackay
et al., 2006; Shafey et al., 2003).
Tobacco-based economy
China is the world’s largest producer and consumer of
tobacco products (Yang et al., 1999): 25.3 billion
cigarettes were imported in 2000, compared with
8.5 billion exported the same year (Shafey et al., 2003).
Chinese economy depends significantly on tobacco
production and cigarette manufacturing (Hu & Mao,
2002a, 2002b). About 0.27% of China’s land (about
1.4 million hectares) is devoted to tobacco production
(Hu & Mao, 2002a; Shafey et al., 2003). Those
involved in the tobacco manufacturing industry and
retail sale of tobacco constituted 0.6% of the total
employed population in 2000 (Hu & Mao, 2002b).
The tobacco industry in China is a state-run enterprise
(Hu & Mao, 2002a, 2002b). The cigarette tax
contributed between 10% and 14% of the total
governmental tax revenue between 1983 and 1997, a
fairly consistent annual contribution (Hu & Mao,
2002b).
Attempts to control the demand and supply of tobacco
Price-based measure. Increasing the price of cigar-
ettes has not been used as a means of tobacco control
in China. China does not have a sales tax system.
Since a retail tax is not levied on cigarettes in China,
a product tax makes up the total tax on cigarettes
(Hu & Mao, 2002a, 2002b) The selling price exhibits
a tax that amounts to about 40% of the value of
cigarettes (Hu & Mao, 2002a, 2002b). The real price
of cigarettes increased almost by 630% between 1980
and 1997 (Hu & Mao, 2002b).
Nonprice measures. In the past decade, China has
introduced a number of bans and restrictions
regarding advertisement, sale, and use of cigarettes.
Advertising tobacco-related products on radio, film,
and television, and in newspapers, magazines and
periodicals is prohibited (Shafey et al., 2003).
Similarly, advertising in public places such as waiting
rooms, cinemas, theaters, conference halls, stadiums,
and gymnasiums is also prohibited. Selling tobacco
to minors (younger than 18) is illegal, though
retailers are not legally required to verify the age of
the customer. The Chinese government collaborates
with other tobacco-control groups in order to
advertise health warnings. In addition, the law
requires manufacturers to have tobacco manufactur-
ing licenses and to include health warnings on
packaging (Shafey et al., 2003); with some variation,
such warnings cover approximately 30% of the face
of the pack. Only 18%–21% of youth reported that
they had been taught in class about the dangers of
smoking during the past year (GYTS—Shanghai,
2004; GYTS—Tianjin, 2004; GYTS—Zhuhai, 2004).
Attempts to control exposure to ETS
According to Tobacco Monopoly Law, smoking is
restricted in government workplaces, public worksites,

and restaurants (Shafey et al., 2003). China’s law on
protection of minors bans smoking in educational
facilities. China’s implementation guideline for the
public place hygiene management regulation does not
allow smoking in health care facilities. Similarly,
China has regulations prohibiting smoking on public
transportation and domestic and international flights
and in waiting rooms (Shafey et al., 2003).
Enforcement of all of these regulatory efforts remains
an ongoing challenge.
Tobacco use cessation efforts
Initially, programming centered on a brief once-a-year
campaign to implement the ‘‘Quit and Win’’ program
(Sun et al., 2000; ‘‘60,000 Chinese smokers join Quit &
Win,’’ 2004), or isolated tobacco use cessation
programs were initiated by local or foreign public
health researchers and organizations (Yang et al.,
2001; Zheng et al., 2004). Currently, an initiative has
been launched in Southwest China’s Yunnan pro-
vince, led by Dr. Kohrman and colleagues at the
Kunming Medical College Tobacco-Control Research
Center. It involves the development of a culturally
suitable, evidence-based, self-help quit manual, and
has involved 2 years of anthropological research and
focus group discussions (Kohrman et al., 2005). When
partnered with policy-based tobacco-control initia-
tives, self-help tools are likely to be effective in China,
because they are inexpensive to produce, are easy to
disseminate, and fit well with quickly emerging
Chinese notions of individualized risk management
(Kohrman, 2004). This manual uses concepts from the
Trans-Theoretical Model (Prochaska, Velicer, Fava,
LaForge, & Ruggiero, 1997). Although still under-
going testing, the manual is already being distributed
nationwide by provincial-level health education insti-
tutes and the Chinese Center for Disease Control and
Prevention.
FCTC status and summary
China signed the FCTC treaty on November 10,
2003, and ratified the treaty on October 11, 2005
(WHO, 2007). It appears that 9 of 11 key policies
have been enacted, national prevalence data have
been collected, and there are some enforcement and
education efforts.
Tobacco control in Thailand
Smoking prevalence
Current adult daily and occasional smoking pre-
valence in Thailand is 37.2% for males, and 2.1% for
females (19.5%, overall; National Statistical Office,
2004). There are no available estimates based on
NICOTINE & TOBACCO RESEARCH S453
adult samples that indicate the degree of exposure to
ETS in Thailand (Mackay et al., 2006). The Thailand
GYTS found that 47.8% of the adolescents said they
lived in homes where others smoked in their presence
and 68.5% reported spending time outside their home
where they are exposed to cigarette smoke (GYTS—
Thailand, 2004).
Tobacco-based economy
In 1995, 0.21% of Thailand’s land—about 42,300
hectares—was used for tobacco growing (Shafey
et al., 2003). In 1998, 0.181 billion cigarette sticks
were exported, while 1.7 billion sticks were imported
(Shafey et al., 2003). As of 2001, the Thai tobacco
industry consisted of a state-owned monopoly—Thai
Tobacco Monopoly (TTM). The tobacco industry
contributes 3.5%–4.5% of the total government
revenue in Thailand (Sarntisart, 2003, 2006).
Attempts to control the demand and supply of tobacco
Price-based measure. The retail price of domestic
cigarette brands includes excise and value-added
taxes. An additional import tariff is imposed on
imported brands (Sarntisart, 2004). In 1994, the
government of Thailand decided to increase the level
of excise tax (Vateesatokit, 2003). Across a decade,
this tax policy resulted in an additional US$1 billion
for the Thai government while helping to reduce the
smoking prevalence in all age groups. The FCTC
calls for a tax rate of at least two thirds of the retail
price of tobacco. The tax on cigarettes has been
raised seven times since 1994 and in 2005 stands at
79% of the base price at the national level (National
Statistical Office, 2004), and 60% of the retail price.
Non-price measures. The first major tobacco-control
regulation in Thailand was the 1989 total ban on
advertising and promoting cigarettes. However, in
1991, the Thai government permitted legal importa-
tion of cigarettes to Thailand as a compromise
position (no advertising allowed) after a 6-year battle
with the transnational tobacco industry, particularly
the U.S. Cigarette Exporting Association (USCEA).
Anti-tobacco forces fought back, and in 1992, the
Tobacco Products Control Act was enacted. This act
restricted advertising of tobacco products on bill-
boards and prohibited the sale of cigarettes to those
under 18, vending machine sales, and the import and
sale of smokeless tobacco. The Tobacco Products
Control Law also prohibited tobacco companies
from advertising through sponsorship of events
(Shafey et al., 2003).
Another big step towards tobacco control in
Thailand involved extensive public educational
campaigns. The Tobacco Consumption Control
S454 TOBACCO CONTROL IN DEVELOPING COUNTRIES
Office (TCCO), a government entity, was established
in 1991. The TCCO and partnership organizations
disseminated anti-tobacco messages about smoking
and its detrimental effects on health, wealth, and
social relationships. Media was effectively used to
disseminate these messages.
Recently, youth activism against tobacco use has
surfaced as another prominent aspect of tobacco-
control efforts in Thailand. For example, these
included public youth demonstrations against the
Philip Morris ASEAN Art Awards in 2004 and
against convenience stores’ resistance to the Ministry
of Health’s new restrictions on tobacco point-of-sale
advertising in 2005.
Attempts to control exposure to ETS
The Nonsmokers’ Health Protection Act of 1992 in
Thailand banned smoking in schools and other
public places. The smoking restrictions of this law
were gradually expanded to include all public
transportation, public buildings, some workplaces,
and restaurants. Though some locales are allowed to
have separate private rooms for smoking, most
public offices, including banks and shopping centers,
are smoke free.
Tobacco use cessation efforts
There have been instances of isolated tobacco cessa-
tion programs across Thailand since the late 1980s,
including one led by Buddhist monks in the district of
Mae Sot, Tak Province (‘‘Influence of Religious
Leaders,’’ 1993). Currently, tobacco use cessation
strategies have been integrated with other measures by
the National Committee for the Control of Tobacco
use, with a focus on training health care professionals
and community health volunteers to motivate smo-
kers to quit (Bhumiswasdi, 2002). Training programs
are organized every year across the country, and
government assistance conferences are organized that
provide opportunities for health professions to discuss
ways of setting up smoking cessation clinics
(Bhumiswasdi, 2002). The Thai government has
prepared a handbook on how to organize and carry
out a 3-day long tobacco cessation-oriented camp for
those seeking innovative techniques to promote
smoking cessation (Bhumiswasdi, 2002).
FCTC status and summary
Thailand signed the FCTC on June 20, 2003, and
ratified the treaty on November 8, 2004 (WHO,
2007). It appears that 10 of the 11 key policies have
been enacted, national prevalence data have been
collected, activism efforts are noted, and there is
some enforcement.
Discussion
There are several limitations to these data. First, use
of the FCTC criteria may not be without limitations.
For example, many researchers might consider the
United States as being advanced in tobacco-control
efforts. Still, while the U.S. signed the agreement on
May 10, 2004, it still has not ratified it. On an
international level, however, the FCTC provides by
far the best means of comparing countries on level of
tobacco-control efforts.
Second, more studies have been published on
tobacco control in some countries (e.g., Thailand)
than others (e.g., Tanzania). In fact, some data (e.g.
smoking prevalence) may not be comparable because
of the differences in survey measures and sampling
methods. In particular, among the case studies
presented in this paper, Tanzania shows the lowest
reported smoking prevalence—23% and 1.3% among
adult men and women respectively (Bovet et al.,
2002). Given this relative prevalence, the relatively
fewer number of tobacco-control measures used in
Tanzania may seem commensurate. However, the
prevalence data for Tanzanians (e.g., Mackay et al.,
2006; Shafey et al., 2003) are based on studies
conducted on relatively small, urban samples (e.g.,
Bovet et al, 2002), which are unlikely to have
adequately represented the more than 37 million
people of Tanzania (Central Intelligence Agency,
2006). Clearly, more surveys based on a representa-
tive sample are required to establish a better idea of
the tobacco use problem in Tanzania.
Third, while 84% overall agreement with the
standard is reasonably high, there was some dis-
agreement. This suggests either error in care of or
preparation for doing the ratings (e.g., no definitions
were provided in the rating material) or some
ambiguity across persons in interpreting the data.
Given the limitations of the data sources and this
ethnographic method, the use of available data
combined with this coding scheme is still a useful
means to begin to gauge country-level tobacco-
control policy, needs for changes in policy, and
monitoring of changes of control policy through
repeated measurements over time.
Based on the results in Table 2, and considering the
different dates of the FCTC ratification, one may
speculate that tobacco control in developing coun-
tries progresses in three general steps: (a) assessment,
awareness, and beginnings of tobacco control often
involving public warnings (‘‘awareness’’ step); (b)
enactment of several policies but with equivocal
national government and local support (‘‘growth’’
step); and (c) enactment and enforcement of a
number of policies that take a relatively strong
tobacco control stance and demonstrate national
government and local activism support (‘‘mature’’
step). According to our evaluation, Tanzania is at the

end of the first step or beginning of the second step,
and Nepal and China are at the second step. In the
third step, as illustrated by Thailand, a mature stance
toward tobacco control is established; the cigarette
tax is used efficiently to reduce cigarette demand and
provide a secure funding base for health promotion,
cessation is included in national programs, and anti-
tobacco activism is encouraged.
These four tobacco control case studies imply to us
that tobacco use is now recognized in the developing
world as a serious threat to national health. The case
studies also suggest that, similar to the more
industrialized nations of the West, countries from
the developing world acknowledge that tobacco use
can be controlled through policy interventions.
Moreover, the fact that these countries integrate
internationally recommended tobacco-control strate-
gies into their own efforts suggests that they are
willing to actively participate in the global move-
ment against tobacco use. The alacrity shown by
some of the developing countries to sign and
ratify the FCTC further suggests that if an inter-
nationally recognized ‘‘codes of conduct’’ regarding
tobacco control is established—much like the
Geneva Conventions regarding humanitarian con-
cerns—then the countries are likely to view it as an
ethical imperative to pledge commitment to such
conventions.
Furthermore, our descriptions illustrate that
tobacco-control efforts vary to some extent across
developing countries; a country can be viewed as
belonging to a more or a less advanced stage of
tobacco control. Classifying countries into such
stages facilitates intercountry comparison, which
may provide direction regarding which countries
are lagging behind others and may need assistance.
Future research is needed across a wider sample of
countries to consider whether the stage perspective
has merit.
Although enactment of policies was described,
enforcement of policies was not described and is
difficult to quantify. According to the first-hand
experience of the authors, in Tanzania there is
virtually no enforcement of any enacted tobacco
policy. In Nepal, most bans and restrictions are not
effectively implemented. Smoking within govern-
ment buildings, private workplaces, and public
transportation is still occurring. However, regula-
tions in air flights and health care facilities have been
effective. Likewise, for nearly all the policies and
interventions enacted for use in China, implementa-
tion has been far from complete. Moreover, two of
the coauthors have observed numerous sales of
tobacco products to minors in rural Thailand.
These observations are anecdotal. Enforcement of
the FCTC policies is supposed to occur through
monitoring, which should be systematic, large-scale,
NICOTINE & TOBACCO RESEARCH S455
and representative. This is not being truly accom-
plished yet in any of these four countries.
Other problems exist that may serve as barriers
to enforcement. For example, some countries in the
developing world, like Nepal, undergo frequent
changes in government leadership. Policy legislation
under one leadership may not be seriously followed
up when another leadership comes to power. In
such countries, only a strong system of monitoring
supported by the press, anti-tobacco activists,
national organizations, and international NGOs
can ensure proper implementation of policies.
There seems to be a rural-urban divide in
developing countries. Urban and rural regions differ
vastly in education, health care, knowledge, and state
monitoring. While the state is quite effective in
enforcing rules and regulations in towns and cities, it
is not as effective in monitoring small towns and
villages, where tobacco-related laws are often over-
looked. We believe this is true in all four countries
examined. One final note is that there may be a lack
of anti-tobacco activism in developing countries.
Absence of activism permits pro-tobacco lobbyists to
easily influence the government and persons in
business. One possible reason why Thailand is
farther ahead in tobacco control than the other
countries, despite similar economic pressures, may be
the longer and stronger anti-tobacco activism com-
pared with the other countries. Change appears to
occur along a developmental trajectory from aware-
ness, to growth of tobacco control, to a mature
stance, the last of which might involve extensive
activism efforts.
Acknowledgements
This paper was supported by grants from the National Institute
on Drug Abuse (#sDA13814, DA016090, DA020138 and P50
DA16094.
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