Association between Tobacco Industry Interference Index (TIII) and MPOWER measures and adult daily smoking prevalence rate in 30 countries

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Methods The TIII was extracted from the Global Tobacco Industry Interference Index 2019 and Global Center for Good Governance in Tobacco Control (GGTC). MPOWER measures and adult daily smoking prevalence rate were extracted from the World Health Organization (WHO) report on the global tobacco epidemic 2021. We assessed the ecological cross-lagged association between TIII and MPOWER scores as well as between TIII and age-standardized prevalence rates for adult daily tobacco users. Results Tobacco industry interference was inversely correlated with a country’s package of tobacco control measures (β=-0.088, P = 0.035). The TIII was correlated with weaker warnings about the dangers of tobacco (β=-0.016, P = 0.078) and lack of enforcement of bans on tobacco advertising promotion and sponsorship (β=-0.023, P = 0.026). In turn, the higher the TIII, the higher the age-standardized prevalence of adult daily smokers of tobacco for both sexes (β = 0.170, P = 0.036). Adult daily smoking prevalence in males (β = 0.417, P = 0.004) were higher in countries where the tobacco industry received incentives that benefited its business. Conclusion Where the interference of the tobacco industries was high, national compliance with the Framework Convention on Tobacco Control (FCTC) was lower and prevalence of adult daily smokers higher. National governments and global society need to work together to minimize the tobacco industry’s efforts to interfere with tobacco control policies. Figures Figure 1 Introduction Tobacco kills more than 8 million people annually. Despite the decline in tobacco smoking exposure in the last decade, tobacco remains the third leading risk factor for attributable disability-adjusted life-years (DALYs) among Level 2 risks defined by the Global Burden of Disease Study ( 1 ). The tobacco industry has long operated and taken many forms for subverting the implementation of public health policies to combat the tobacco epidemic. Meanwhile, the tobacco industry has relentlessly promoted tobacco sales, despite knowing that tobacco damages people’s health for decades. The tobacco companies have been blamed for blocking, delaying, weakening national tobacco control policies and World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC, which was adopted in 2005. The Guidelines for implementation of Article 5.3, which was approved in 2008 ( 2 ), requires FCTC Parties to protect public health policies from commercial and other vested interests of the tobacco industry. In 2008, the WHO identified a package of measures under the acronym of MPOWER for reducing global morbidity and mortality with tobacco use through monitoring the implementation of the WHO FCTC and national tobacco control policies such as taxation, indoor smoking restrictions, contents regulation and disclosure, packaging and labeling, public awareness, banning promotion and sponsorship, prohibiting sales to minors and illicit trade etc. ( 3 ). The MPOWER policy package has been effective in reducing cigarette smoking among adults ( 4 ). Husain et al. found that countries with higher tobacco control preparedness showed a significant reduction in daily adult smoking prevalence ( 5 ). Regarding the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017, a unit increase of the MPOWER Score was associated with a 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence in High MPOWER/high prevalence and High MPOWER/low prevalence countries, respectively ( 5 ). Additionally, the WHO FCTC acknowledged the effect of diverse factors - trade liberalization, foreign direct investment, global marketing, transnational tobacco advertising, promotion, and sponsorship ( 6 ) – as facilitators in spreading the tobacco epidemic with cross-border effects ( 7 ). Recently, tobacco industries have taken the Covid-19 pandemic as an opportunity to participate in relief efforts by donating ventilators, personal protective equipment, and cash to low- and middle-income countries to project a corporate image of social responsibility ( 8 ). The tobacco industry's activities have undoubtedly hindered the adoption and operation of effective tobacco control policies at the global and the national level ( 9 ). Tobacco industry interference has taken many forms including: 1) influencing the political and legislative process through lobbying and political donations; 2) exaggerating the economic importance of the industry; 3) manipulating public opinion; 4) fabricating support through front groups; 5) discrediting proven science, and 6) intimidating governments with litigation. To our knowledge, no studies have attempted to empirically examine how successful the tobacco industry's attempts have been to interfere with the implementation of tobacco control policies. To address this gap, this study includes three aims: 1) to explore the association between the Tobacco Industry Inference Index (TIII) and MPOWER scores and TIII and adult daily smoking prevalence across 30 countries; 2) to investigate the association between the subcomponents of the TIII and the subcomponents of the MPOWER package; and 3) to explore the various types of TIII and the gender stratified adult daily smoking prevalence. Methods Data sources The TIII was obtained from the Global Center for Good Governance in Tobacco Control (GGTC), which collects and publishes information. The index released in 2019 included 33 countries from Africa, the Eastern Mediterranean region, Latin and North America, Europe, Asia, and the Western Pacific region. After excluding missing data, 30 countries were analyzed. The TIII is based on publicly available information on tobacco industry interference in countries and their respective governments’ responses to this interference in implementing the WHO FCTC Article 5.3 and its Guidelines from January 2017 to December 2018 ( 10 ). The MPOWER scores were obtained from the WHO report on the Global Tobacco Epidemic 2021 based on the results of surveys completed in 2018 and 2019. The latest Adult daily smoking prevalence 2019 was collected from the 2021 WHO report summarizing the age-standardized prevalence rates for adult daily smokers of tobacco in both sexes ( 11 ). Variables The TIII (range 0-100) estimates the response of governments to tobacco industry interference and their public health policies from vested interests as required under the WHO FCTC. Thus, the higher the TIII score, the higher the overall level of tobacco industry interference. For example, the TIII score of the Dominican Republic is 96, indicating a very active and strong tobacco industry interference, whereas Brunei Darussalam scored the lowest of 15, showing a strong government power to regulate the tobacco industries. The TIII includes seven subcomponents: 1) ‘participation in policy development’ which means the tobacco industry interfered in tobacco control public policy generation and implementation (4 categories, 0–20 scores); 2) ‘tobacco-related corporate social responsibility (CSR) activities’ which means the government receives contributions from the tobacco industry or participates in tobacco industry CSR activities (1 category, 0–5 scores); 3) ‘benefits to the tobacco industry’ which means the tobacco industry received incentives that benefited its business (2 categories, 0–10 scores); 4) ‘forms of unnecessary interaction’ which means inappropriate interactions occurred between governments and the industry (3 categories, 0–15 scores); 5) (level of non-) ‘transparency’ which means the government does not publicly disclose interactions with the tobacco industry (2 categories, 0–10 scores); and 6) ‘conflict of interest’ which means that public officials faced conflicts of interest situations (3 categories, 0–15 scores), and 7) ‘preventive measures’ which mean that governments have acted to protect themselves with preventive measures (5 categories, 0–25 scores, reverse coding). The MPOWER package comprises evidence-based tobacco control measures, including six proven policies. M contains monitoring tobacco use and preventive measures and five attainment levels for each other components ( 5 ). P means protecting the population from cigarette smoke, such as designing non-smoking areas in public places. O indicates help to quit tobacco use, such as smoking cessation clinics or cessation call centers. W consists of packaging a health warning about the dangers of tobacco (W1) and implementing a non-smoking campaign for cigarette risk (W2). E summarizes advertising restrictions on tobacco promotion and sponsorship. R means raising taxes on tobacco. For scoring, the M policy dimension ranges from 1 (lowest) to 4 (highest) attainment level. All other POWER policy dimension, the score ranges from 1 (weakest) to 5 (strongest) policies. Since there are seven MPOWER categories, the minimum MPOWER score is 7, and the maximum achievable MPOWER score is 4 + (5×6) or 34 ( 12 ). A high MPOWER score indicates a strong tobacco control in the country ( 13 ). We used the same manner of the latest study ( 5 ) using MPOWER Scores by excluding R (the taxation component) which ranges from a minimum of 6 to a maximum of 29 in our analysis: MPOWE(R). Aggregated MPOWER scores help to generate consistent ranking of implementation status across countries and over time. Adult daily smoking prevalence is age-standardized prevalence rates for adult daily smokers (aged 15 years or older) of tobacco in both sexes, which was constructed to compare tobacco use prevalence estimates across multiple countries or various periods of the same country. Daily cigarette smoking use varies between surveys but usually measures the use of cigarette at least once a day. Statistical analysis Three analyses were performed using a nation as a unit of analysis: Ecological analysis and cross-lagged panel model was applied. First, co-adjusted multiple regressions were performed on the association between the TIII and MPOWER scores and TIII and adult daily smoking prevalence. Second, decomposition regression analyses were measured to understand the MPOWER package score and seven subcomponents of MPOWER measures. Third, gender stratified regression analysis between decomposed TIII and adult daily smoking prevalence was conducted. Statistical significance was determined as a p-value of < 0.05 in a two-sided manner. All statistical analysis was performed with SPSS 25.0 (SPSS Inc, Chicago, IL, USA). Ethical statement This study was exempt from institutional review board approval because we used publicly available data, which contained no personal identifiers. Results An inverse association (β=-0.088, P = 0.035) between the TIII and MPOWER scores was found in unadjusted regression analysis. In contrast, the TIII showed a marginally positive association with age-standardized prevalence rates for adult daily smokers of tobacco in both sexes (β = 0.945, P = 0.006) after mutual statistical adjustment (Fig. 1). Cross-sectional association between TIII (2021) and the MPOWER scores (β=-0.083, P = 0.004) and adult daily smoking prevalence (2021) (β = 0.162, P = 0.083) in 72 countries showed similar results (Figure S1, Table S1-5). There was no statistically correlation between the TIII and MPOWER scores in countries with state-owned tobacco companies (SOTCs), and in Lebanon and Japan, where the governments are the major stakeholders of tobacco companies (β=-0.037, P = 0.617) (Table S2). Among subcomponents of the TIII, as the prevention measures such as the government’s procedures for disclosing records of the interaction with the tobacco industry, programs to consistently raise awareness on policies relating to FCTC Article 5.3 Guidelines increased, the MPOWER package got lowered (β=-0.240, P = 0.035) (Table 1). The TIII was inversely associated with E (enforcing bans on tobacco advertising promotion and sponsorship, TAPS) (β=-0.023, P = 0.026) which means that the more vulnerable countries to the tobacco industry interference, the lower the degree of a TAPS policies. Countries with a higher degree of tobacco interference were less likely to inform the public of the dangers of tobacco through health warning labels (β=-0.016, P = 0.078). The greater the tobacco industries’ tobacco-related CSR activities, the lower the enforcement of package warnings about the dangers of tobacco (β=-0.179, P = 0.030) (Table 2) . On the other hand, the TIII showed no significant association with other MPOWER components such as M (monitor tobacco use and preventive policies), P (protect from tobacco smoke), O (offer help to quit tobacco use), and R (raise taxes on tobacco) (Table 2). In the gender stratified analysis, the greater the TIII, the higher age-standardized prevalence rates for adult daily smokers of tobacco among males (β = 0.417, P = 0.004), whereas there was no significant association among females (β=-0.062, P = 0.390). In the decomposed analysis looking at each component of the TIII, adult daily smoking prevalence in the male group was higher in countries where the tobacco industry received incentives in the form of business ‘benefits to the tobacco industries’ (β = 2.073, P = 0.036), the government receives contributions from the tobacco industry or participates in tobacco industry CSR activities ‘Tobacco-related CSR Activities’ (β = 3.099, P = 0.020), ‘Participation in Policy Development’ by tobacco industries (β = 0.463, P = 0.023), and inappropriate interactions occurred between governments and the industry ‘Forms of Unnecessary Interaction’ (β = 1.093, P = 0.036) (Table 3) . Discussion An inverse association between the TIII and MPOWER measures and a positive association between the TIII and adult daily smoking prevalence was found. The higher the benefit to tobacco industries or fewer the preventive measures, the lower the country’s MPOWER package implementation. Countries with high tobacco industry interference had a low level of tobacco hazard warning policy or tobacco advertising prohibition policy. Where the tobacco industry received incentives that benefited its business and public officials faced conflicts of interest with tobacco companies, smoking prevalence was high in countries. For tobacco industry interference and majority of adult daily smoking, there was little effect in females, but there was a positive effect shown among males. WHO Article 5.3 has a set of guideline recommendations on awareness-raising, limiting interaction with the tobacco industry, rejection of industry partnerships, avoidance of conflicts of interest, transparency, denormalization of industry CSR activities, preferential treatment of the tobacco industry, and state-owned tobacco industries ( 13 ). According to Fooks et al., only 6% of parties have introduced more than half of the requirements of Article 5.3. and 16% of guideline recommendations have been implemented among parties, implying an extensive opportunity for tobacco industry influence ( 14 ). Parties need to remain alert and ensure that Article 5.3 is implemented across different government sectors, aiming at policy coherence that does not favor the interests of tobacco industry over parties’ obligations under the FCTC ( 15 ). United States of America (USA) who has leading cigarette manufacturing remains a non-ratified FCTC party ( 16 ). The study results support the previous findings that tobacco industry’s interference weakens the national tobacco control policy or MPOWER package ( 2 , 17 ). Our results confirmed an argument that tobacco companies' strategies interfered with tobacco control policies which might contribute to increasing the smoking prevalence. When the government’s preventive measures against interference in the tobacco industry were insufficient, or when the tobacco industry benefited greatly, the implementation of FCTC and MPOWER scores were lower. In particular, the tobacco industry exerted a powerful force to block the policy of inserting warnings or pictures on tobacco packages or weaken the ban on sponsoring advertisements for tobacco products. This study identifies that several measures protecting tobacco control policies from the commercial and other vested interests of the tobacco industry have not yet served to completely prevent the tobacco industry from interfering with tobacco control policies ( 2 ). The study results also show higher rates of male smoking in countries where public officials face conflicts of interest, consistent with Article 5.3 guidelines recommending making rules for public servants to avoid conflicts of interest for protecting public health policies from interference with the tobacco industry ( 18 ). Legislators have become vulnerable to tobacco business interference by receiving political contributions ( 19 ). The study also found that the greater the tobacco interference, the lower level of warning about the dangers of tobacco which shows tobacco companies use packaging and other advertising techniques to make cigarettes attractive and misrepresent the fact that tobacco products are detrimental to health ( 20 ). In addition, we found that enforcement of bans on TAPS decreased as tobacco business interference increased, contrary to Article 13 of the FCTC. We recommend that all tobacco industry interference with TAPS should be regulated, including direct advertising bans such as mass media, outdoor advertising, point-of-sale (POS) advertising materials, indirect advertising bans inducing brand stretching, brand sharing, and product placement, etc. ( 21 ) This study also supports the previous hypothesis that countries with high tobacco industry interference have more problems with tobacco use or smoking epidemics ( 22 ). The sabotage strategy from the tobacco industry weakens the MPOWER package and national tobacco control level. Our study results showed that tobacco industry’s activities increased the population's tobacco consumption, confirming that the tobacco industry might be a primary facilitator of the tobacco epidemic. Meanwhile, tobacco use can be explained as the tobacco user as a host, tobacco product as an agent, and policy or media as an environment ( 23 ). Eliminating tobacco industry from health policy design might be the most effective measure that governments can adopt to protect tobacco control activities, thereby averting the number of deaths and diseases caused by the tobacco epidemic ( 13 ). The results show that the tobacco industry's influence on the smoking prevalence rate is more significant for males than females. Given the smoking epidemic in women generally lagging behind men by 30–40 years ( 24 ), it is expected that smoking among women will increase first among those with higher socioeconomic status, as it did with men several decades prior, and a gap between gender will continue to narrow ( 25 ). In this context, tobacco business activities could impact the increase in the smoking rate for both sexes. One of the strongest indicators of conflict of interest is whether the government owns the tobacco companies through weak tobacco control in SOTCs such as low tax rates, no indoor smoking restrictions, sales tobacco products to youth, and loose advertising regulations, etc. ( 26 ) Countries in which the government monopolizes the production and sales of tobacco products or owns at least one tobacco company must have a high TIII score based on a conflict of interest. Contrary to expectation, the TIII scores were not significantly higher in SOTCs. One possible reason based on economic theory might be that tobacco company monopolies lack competitive incentives to actively engage in sales tactics such as mass advertising and encouraging sales to youth and women. The other possible reason is the small sample size for countries with SOTCs. Some limitations that need to be considered when interpreting the results. First, our findings from the 30 selected countries may not be generalizable to a wider pool of countries. Second, measurement errors need to be considered. Random measurement error in the exposure variable will bias associations towards the null ( 27 ). Previous studies have used TIII as an exposure variable. In a study that evaluated the degree of FCTC 5.3 implementation in seven Asian countries using the TIII, the scoring system was designed with the help of tobacco control experts and validated through focused group discussion ( 28 ). Hoe et al. have argued that one of the most cited barriers to tobacco control policy implementation around the world is tobacco industry interference, while TIII 2019 showed that adherence to Article 5.3 had been far from satisfactory worldwide ( 29 ). Jeffrey Drope et al. found strong evidence that interference in tobacco control policymaking has increased in some countries in Latin America with the assessment results using the TIII 2020 ( 30 ). Conclusion As the national compliance with the FCTC decreased, prevalence rates for adult daily smokers of tobacco increased if the interference of the tobacco industries was high. Tobacco industry tactics have been evolving to promote and grow tobacco businesses. Thus, it is crucial to resist tobacco industry disturbances to protect public health and save lives from harmful use of tobacco. Governments and global society should counter against tobacco industry interference to protect public health and advance tobacco control policies. Abbreviations TIII (Tobacco Industry Interference Index) GGTC (Global Center for Good Governance in Tobacco Control) WHO (World Health Organization) FCTC (Framework Convention on Tobacco Control) DALYs (Disability Adjusted Life Years) SOTCs (State Owned Tobacco Companies) TAPS (Tobacco Advertising Promotion and Sponsorship) CSR (Corporate Social Responsibility) Declarations Ethical approval and consent to participate Not applicable. Consent for publication Not applicable Availability of data and materials Publicly available data are used in the study. All data relevant to the study are provided with the sources in the article. Competing interests The authors declare that they have no competing interest. Funding Not applicable. Authors’ contributions JO and YL conceived the study. YL curated data and did the formal analysis. JO led the investigation and designed the methodology. SK and YL validated the data. YR wrote the original draft. MK reviewed and edited the manuscript. IK and JO supervised the study. All authors reviewed, revised, and approved the manuscript. All authors had access to all the data in the study and had final responsibility for the decision to submit for publication. Acknowledgments We thank the Global Center for Good Governance in Tobacco Control (Bangkok, Thailand) who provided data for this article. 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Special Issue Tobacco Control. http://dx.doi.org/10.26633/rpsp.2022.111 . Tables Table 1. Impact of the subcomponents of the Tobacco Industry Interference (TIII) on MPOWER scores in 30 countries Variable MPOWER Scores (2021) β P-value Tobacco Industry Interference Index (2019) -0.055 0.125 Participation in Policy Development -0.186 0.121 Tobacco-related CSR Activities -0.348 0.296 Benefits to the Tobacco Industry -0.139 0.527 Forms of Unnecessary Interaction -0.069 0.591 Conflict of Interest -0.166 0.560 Transparency 0.027 0.882 Preventive Measures -0.240* 0.035 Note: P<0.05* Table 2. Impact of the Subcomponents of the TIII on Subcomponents of the MPOWER package in 30 countries Variable M P O W(1) W(2) E R β P-value β P-value β P-value β P-value β P-value β P-value β P-value Tobacco Industry Interference Index (2019) -0.003 0.766 -0.019 0.193 0.003 0.793 -0.016 0.078 0.005 0.738 -0.023* 0.026 -0.002 0.854 Participation in Policy Development -0.005 0.883 -0.081 0.086 0.015 0.630 -0.045 0.140 0.035 0.442 -0.067 0.051 -0.038 0.263 Tobacco-related CSR Activities -0.079 0.382 -0.149 0.257 0.000 1.000 -0.179* 0.030 0.188 0.125 -0.111 0.250 -0.020 0.837 Benefits to the Tobacco Industry 0.051 0.381 -0.065 0.452 -0.036 0.529 -0.040 0.472 -0.011 0.892 -0.038 0.549 0.000 1.000 Forms of Unnecessary Interaction -0.021 0.550 -0.007 0.892 0.014 0.680 -0.036 0.272 0.002 0.967 -0.036 0.323 0.015 0.681 Conflict of Interest 0.053 0.490 0.020 0.858 0.015 0.839- -0.048 0.512 0.003 0.981 -0.146 0.070 -0.033 0.686 Transparency -0.009 0.851 -0.023 0.754 0.046 0.326 0.007 0.881 0.031 0.647 -0.082 0.112 0.057 0.267 Preventive Measures -0.019 0.552 -0.068 0.138 -0.007 0.832 -0.056 0.058 -0.021 0.640 -0.058 0.085 -0.013 0.707 Note: P<0.05*. M contains monitoring tobacco use and preventive measures and five attainment levels for each other components. P means protecting the population from cigarette smoke, such as designing non-smoking areas in public places. O indicates help to quit tobacco use, such as smoking cessation clinics or cessation call centers. W consists of packaging a health warning about the dangers of tobacco (W1) and implementing a non-smoking campaign for cigarette risk (W2). E summarizes advertising on tobacco ban, promotion and sponsorship. R means raising taxes on tobacco. Table 3. Impact of the Subcomponents of the TIII on Adult Daily Smoking Prevalence by Gender in 30 countries Variable Adult daily smoking prevalence (2021) Both Sexes Male Female β P-value β P-value β P-value Tobacco Industry Interference Index (2019) 0.170* 0.036 0.417* 0.004 -0.062 0.390 Participation in Policy Development 0.513 0.060 0.463* 0.023 -0.040 0.868 Tobacco-related CSR Activities 0.772 0.314 3.099* 0.020 -1.534* 0.014 Benefits to the Tobacco Industry 0.944 0.053 2.073* 0.017 -0.170 0.691 Forms of Unnecessary Interaction 0.511 0.074 1.093* 0.036 0.005 0.985 Conflict of Interest 0.636 0.328 2.081 0.070 -0.806 0.141 Transparency 0.270 0.517 1.264 0.102 -0.688* 0.045 Preventive Measures 0.225 0.346 0.519 0.305 0.067 0.774 Note: P<0.05* Supplementary Files SupplementaryFiles.docx Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2024 Read the published version in Globalization and Health → Version 1 posted Editorial decision: Major Revision 21 Jul, 2023 Reviewers agreed at journal 22 Jun, 2023 Reviewers invited by journal 14 Jun, 2023 Editor assigned by journal 09 Jun, 2023 First submitted to journal 05 Jun, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3021903","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":209942778,"identity":"685ce326-907f-4de9-b867-d647864d4ad6","order_by":0,"name":"Yuri Lee","email":"","orcid":"","institution":"Myong-Ji University: Myongji University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuri","middleName":"","lastName":"Lee","suffix":""},{"id":209942779,"identity":"158675cd-cf40-404a-86c6-46c7e760bc0d","order_by":1,"name":"Siwoo Kim","email":"","orcid":"","institution":"Seoul National University College of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Siwoo","middleName":"","lastName":"Kim","suffix":""},{"id":209942780,"identity":"da5da35c-ee00-48da-bd07-1a8a73464e5c","order_by":2,"name":"Min Kyung Kim","email":"","orcid":"","institution":"Tufts Clinical and Translational Science Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Min","middleName":"Kyung","lastName":"Kim","suffix":""},{"id":209942781,"identity":"e30af235-4b5e-4157-9f1f-76958328411a","order_by":3,"name":"Ichiro Kawachi","email":"","orcid":"","institution":"Harvard University HSPH: Harvard University T H Chan School of Public Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ichiro","middleName":"","lastName":"Kawachi","suffix":""},{"id":209942782,"identity":"2f40074b-9da3-435b-9246-12a2dcb157f0","order_by":4,"name":"Juhwan Oh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYDACCfaDDz5UwHgHiNLCk2w44wxpWhjMpHnbSNHCL92QIDlzXl2ewQHmhx8YztwjrEVyzsEDBh+3HS42OMBmLMFwo5iwFoMbCQmJM7cdSNxwgMGMgeFDAlFaDA7zzqkDamH/RrQWw2beBmagFh6gLTeI0CI5IyeZccaxw4kzD/MUSyScIUILv0T68R8fauoS+463b/zw4RgRWhCAGYhJ0jAKRsEoGAWjADcAAKLqPzoFMmRVAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0003-0983-4872","institution":"Seoul National University College of Medicine","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Juhwan","middleName":"","lastName":"Oh","suffix":""}],"badges":[],"createdAt":"2023-06-05 00:02:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3021903/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3021903/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12992-023-01003-x","type":"published","date":"2024-01-03T15:01:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":38676916,"identity":"92896320-2e14-4aef-aef5-4ace654b9fc6","added_by":"auto","created_at":"2023-06-16 15:36:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48506,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCross-lagged Association between Tobacco Industry Interference Index (TIII) and MPOWER scores and adult daily smoking prevalence in 30 countries\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3021903/v1/f2ffde112b4985c28812c23e.png"},{"id":49315402,"identity":"3db0ef69-6bd3-40ac-badb-e6e84ba129f0","added_by":"auto","created_at":"2024-01-08 15:06:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":437778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3021903/v1/f6546f91-19df-45cd-9b2d-d0d977462039.pdf"},{"id":38677250,"identity":"31681a90-f2ee-4d68-8dc4-3a7f155dcaeb","added_by":"auto","created_at":"2023-06-16 15:44:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":72528,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-3021903/v1/5dad517895257b4ad6e01166.docx"}],"financialInterests":"","formattedTitle":"Association between Tobacco Industry Interference Index (TIII) and MPOWER measures and adult daily smoking prevalence rate in 30 countries","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTobacco kills more than 8\u0026nbsp;million people annually. Despite the decline in tobacco smoking exposure in the last decade, tobacco remains the third leading risk factor for attributable disability-adjusted life-years (DALYs) among Level 2 risks defined by the Global Burden of Disease Study (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The tobacco industry has long operated and taken many forms for subverting the implementation of public health policies to combat the tobacco epidemic. Meanwhile, the tobacco industry has relentlessly promoted tobacco sales, despite knowing that tobacco damages people\u0026rsquo;s health for decades. The tobacco companies have been blamed for blocking, delaying, weakening national tobacco control policies and World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC, which was adopted in 2005. The Guidelines for implementation of Article 5.3, which was approved in 2008 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), requires FCTC Parties to protect public health policies from commercial and other vested interests of the tobacco industry.\u003c/p\u003e \u003cp\u003eIn 2008, the WHO identified a package of measures under the acronym of MPOWER for reducing global morbidity and mortality with tobacco use through monitoring the implementation of the WHO FCTC and national tobacco control policies such as taxation, indoor smoking restrictions, contents regulation and disclosure, packaging and labeling, public awareness, banning promotion and sponsorship, prohibiting sales to minors and illicit trade etc. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The MPOWER policy package has been effective in reducing cigarette smoking among adults (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Husain et al. found that countries with higher tobacco control preparedness showed a significant reduction in daily adult smoking prevalence (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Regarding the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017, a unit increase of the MPOWER Score was associated with a 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence in High MPOWER/high prevalence and High MPOWER/low prevalence countries, respectively (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Additionally, the WHO FCTC acknowledged the effect of diverse factors - trade liberalization, foreign direct investment, global marketing, transnational tobacco advertising, promotion, and sponsorship (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) \u0026ndash; as facilitators in spreading the tobacco epidemic with cross-border effects (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Recently, tobacco industries have taken the Covid-19 pandemic as an opportunity to participate in relief efforts by donating ventilators, personal protective equipment, and cash to low- and middle-income countries to project a corporate image of social responsibility (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe tobacco industry's activities have undoubtedly hindered the adoption and operation of effective tobacco control policies at the global and the national level (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Tobacco industry interference has taken many forms including: 1) influencing the political and legislative process through lobbying and political donations; 2) exaggerating the economic importance of the industry; 3) manipulating public opinion; 4) fabricating support through front groups; 5) discrediting proven science, and 6) intimidating governments with litigation.\u003c/p\u003e \u003cp\u003eTo our knowledge, no studies have attempted to empirically examine how successful the tobacco industry's attempts have been to interfere with the implementation of tobacco control policies. To address this gap, this study includes three aims: 1) to explore the association between the Tobacco Industry Inference Index (TIII) and MPOWER scores and TIII and adult daily smoking prevalence across 30 countries; 2) to investigate the association between the subcomponents of the TIII and the subcomponents of the MPOWER package; and 3) to explore the various types of TIII and the gender stratified adult daily smoking prevalence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData sources\u003c/h2\u003e \u003cp\u003eThe TIII was obtained from the Global Center for Good Governance in Tobacco Control (GGTC), which collects and publishes information. The index released in 2019 included 33 countries from Africa, the Eastern Mediterranean region, Latin and North America, Europe, Asia, and the Western Pacific region. After excluding missing data, 30 countries were analyzed. The TIII is based on publicly available information on tobacco industry interference in countries and their respective governments’ responses to this interference in implementing the WHO FCTC Article 5.3 and its Guidelines from January 2017 to December 2018 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe MPOWER scores were obtained from the WHO report on the Global Tobacco Epidemic 2021 based on the results of surveys completed in 2018 and 2019. The latest Adult daily smoking prevalence 2019 was collected from the 2021 WHO report summarizing the age-standardized prevalence rates for adult daily smokers of tobacco in both sexes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eVariables\u003c/h2\u003e \u003cp\u003eThe TIII (range 0-100) estimates the response of governments to tobacco industry interference and their public health policies from vested interests as required under the WHO FCTC. Thus, the higher the TIII score, the higher the overall level of tobacco industry interference. For example, the TIII score of the Dominican Republic is 96, indicating a very active and strong tobacco industry interference, whereas Brunei Darussalam scored the lowest of 15, showing a strong government power to regulate the tobacco industries.\u003c/p\u003e \u003cp\u003eThe TIII includes seven subcomponents: 1) ‘participation in policy development’ which means the tobacco industry interfered in tobacco control public policy generation and implementation (4 categories, 0–20 scores); 2) ‘tobacco-related corporate social responsibility (CSR) activities’ which means the government receives contributions from the tobacco industry or participates in tobacco industry CSR activities (1 category, 0–5 scores); 3) ‘benefits to the tobacco industry’ which means the tobacco industry received incentives that benefited its business (2 categories, 0–10 scores); 4) ‘forms of unnecessary interaction’ which means inappropriate interactions occurred between governments and the industry (3 categories, 0–15 scores); 5) (level of non-) ‘transparency’ which means the government does not publicly disclose interactions with the tobacco industry (2 categories, 0–10 scores); and 6) ‘conflict of interest’ which means that public officials faced conflicts of interest situations (3 categories, 0–15 scores), and 7) ‘preventive measures’ which mean that governments have acted to protect themselves with preventive measures (5 categories, 0–25 scores, reverse coding).\u003c/p\u003e \u003cp\u003eThe MPOWER package comprises evidence-based tobacco control measures, including six proven policies. M contains monitoring tobacco use and preventive measures and five attainment levels for each other components (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). P means protecting the population from cigarette smoke, such as designing non-smoking areas in public places. O indicates help to quit tobacco use, such as smoking cessation clinics or cessation call centers. W consists of packaging a health warning about the dangers of tobacco (W1) and implementing a non-smoking campaign for cigarette risk (W2). E summarizes advertising restrictions on tobacco promotion and sponsorship. R means raising taxes on tobacco.\u003c/p\u003e \u003cp\u003eFor scoring, the M policy dimension ranges from 1 (lowest) to 4 (highest) attainment level. All other POWER policy dimension, the score ranges from 1 (weakest) to 5 (strongest) policies. Since there are seven MPOWER categories, the minimum MPOWER score is 7, and the maximum achievable MPOWER score is 4 + (5×6) or 34 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A high MPOWER score indicates a strong tobacco control in the country (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We used the same manner of the latest study (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) using MPOWER Scores by excluding R (the taxation component) which ranges from a minimum of 6 to a maximum of 29 in our analysis: MPOWE(R). Aggregated MPOWER scores help to generate consistent ranking of implementation status across countries and over time.\u003c/p\u003e \u003cp\u003eAdult daily smoking prevalence is age-standardized prevalence rates for adult daily smokers (aged 15 years or older) of tobacco in both sexes, which was constructed to compare tobacco use prevalence estimates across multiple countries or various periods of the same country. Daily cigarette smoking use varies between surveys but usually measures the use of cigarette at least once a day.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThree analyses were performed using a nation as a unit of analysis: Ecological analysis and cross-lagged panel model was applied. First, co-adjusted multiple regressions were performed on the association between the TIII and MPOWER scores and TIII and adult daily smoking prevalence. Second, decomposition regression analyses were measured to understand the MPOWER package score and seven subcomponents of MPOWER measures. Third, gender stratified regression analysis between decomposed TIII and adult daily smoking prevalence was conducted. Statistical significance was determined as a p-value of \u0026lt; 0.05 in a two-sided manner. All statistical analysis was performed with SPSS 25.0 (SPSS Inc, Chicago, IL, USA).\u003c/p\u003e \u003cp\u003e \u003ch2\u003eEthical statement\u003c/h2\u003e \u003cp\u003eThis study was exempt from institutional review board approval because we used publicly available data, which contained no personal identifiers.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAn inverse association (β=-0.088, P = 0.035) between the TIII and MPOWER scores was found in unadjusted regression analysis. In contrast, the TIII showed a marginally positive association with age-standardized prevalence rates for adult daily smokers of tobacco in both sexes (β = 0.945, P = 0.006) after mutual statistical adjustment \u003cb\u003e(Fig.\u0026nbsp;1).\u003c/b\u003e Cross-sectional association between TIII (2021) and the MPOWER scores (β=-0.083, P = 0.004) and adult daily smoking prevalence (2021) (β = 0.162, P = 0.083) in 72 countries showed similar results \u003cb\u003e(Figure S1, Table S1-5).\u003c/b\u003e There was no statistically correlation between the TIII and MPOWER scores in countries with state-owned tobacco companies (SOTCs), and in Lebanon and Japan, where the governments are the major stakeholders of tobacco companies (β=-0.037, P = 0.617) \u003cb\u003e(Table S2).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAmong subcomponents of the TIII, as the prevention measures such as the government’s procedures for disclosing records of the interaction with the tobacco industry, programs to consistently raise awareness on policies relating to FCTC Article 5.3 Guidelines increased, the MPOWER package got lowered (β=-0.240, P = 0.035) \u003cb\u003e(Table\u0026nbsp;1).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe TIII was inversely associated with E (enforcing bans on tobacco advertising promotion and sponsorship, TAPS) (β=-0.023, P = 0.026) which means that the more vulnerable countries to the tobacco industry interference, the lower the degree of a TAPS policies. Countries with a higher degree of tobacco interference were less likely to inform the public of the dangers of tobacco through health warning labels (β=-0.016, P = 0.078). The greater the tobacco industries’ tobacco-related CSR activities, the lower the enforcement of package warnings about the dangers of tobacco (β=-0.179, P = 0.030) \u003cb\u003e(Table\u0026nbsp;2)\u003c/b\u003e. On the other hand, the TIII showed no significant association with other MPOWER components such as M (monitor tobacco use and preventive policies), P (protect from tobacco smoke), O (offer help to quit tobacco use), and R (raise taxes on tobacco) \u003cb\u003e(Table\u0026nbsp;2).\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn the gender stratified analysis, the greater the TIII, the higher age-standardized prevalence rates for adult daily smokers of tobacco among males (β = 0.417, P = 0.004), whereas there was no significant association among females (β=-0.062, P = 0.390). In the decomposed analysis looking at each component of the TIII, adult daily smoking prevalence in the male group was higher in countries where the tobacco industry received incentives in the form of business ‘benefits to the tobacco industries’ (β = 2.073, P = 0.036), the government receives contributions from the tobacco industry or participates in tobacco industry CSR activities ‘Tobacco-related CSR Activities’ (β = 3.099, P = 0.020), ‘Participation in Policy Development’ by tobacco industries (β = 0.463, P = 0.023), and inappropriate interactions occurred between governments and the industry ‘Forms of Unnecessary Interaction’ (β = 1.093, P = 0.036) \u003cb\u003e(Table\u0026nbsp;3)\u003c/b\u003e.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eAn inverse association between the TIII and MPOWER measures and a positive association between the TIII and adult daily smoking prevalence was found. The higher the benefit to tobacco industries or fewer the preventive measures, the lower the country’s MPOWER package implementation. Countries with high tobacco industry interference had a low level of tobacco hazard warning policy or tobacco advertising prohibition policy. Where the tobacco industry received incentives that benefited its business and public officials faced conflicts of interest with tobacco companies, smoking prevalence was high in countries. For tobacco industry interference and majority of adult daily smoking, there was little effect in females, but there was a positive effect shown among males.\u003c/p\u003e\u003cp\u003eWHO Article 5.3 has a set of guideline recommendations on awareness-raising, limiting interaction with the tobacco industry, rejection of industry partnerships, avoidance of conflicts of interest, transparency, denormalization of industry CSR activities, preferential treatment of the tobacco industry, and state-owned tobacco industries (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to Fooks et al., only 6% of parties have introduced more than half of the requirements of Article 5.3. and 16% of guideline recommendations have been implemented among parties, implying an extensive opportunity for tobacco industry influence (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Parties need to remain alert and ensure that Article 5.3 is implemented across different government sectors, aiming at policy coherence that does not favor the interests of tobacco industry over parties’ obligations under the FCTC (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). United States of America (USA) who has leading cigarette manufacturing remains a non-ratified FCTC party (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study results support the previous findings that tobacco industry’s interference weakens the national tobacco control policy or MPOWER package (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Our results confirmed an argument that tobacco companies' strategies interfered with tobacco control policies which might contribute to increasing the smoking prevalence. When the government’s preventive measures against interference in the tobacco industry were insufficient, or when the tobacco industry benefited greatly, the implementation of FCTC and MPOWER scores were lower. In particular, the tobacco industry exerted a powerful force to block the policy of inserting warnings or pictures on tobacco packages or weaken the ban on sponsoring advertisements for tobacco products. This study identifies that several measures protecting tobacco control policies from the commercial and other vested interests of the tobacco industry have not yet served to completely prevent the tobacco industry from interfering with tobacco control policies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The study results also show higher rates of male smoking in countries where public officials face conflicts of interest, consistent with Article 5.3 guidelines recommending making rules for public servants to avoid conflicts of interest for protecting public health policies from interference with the tobacco industry (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Legislators have become vulnerable to tobacco business interference by receiving political contributions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study also found that the greater the tobacco interference, the lower level of warning about the dangers of tobacco which shows tobacco companies use packaging and other advertising techniques to make cigarettes attractive and misrepresent the fact that tobacco products are detrimental to health (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In addition, we found that enforcement of bans on TAPS decreased as tobacco business interference increased, contrary to Article 13 of the FCTC. We recommend that all tobacco industry interference with TAPS should be regulated, including direct advertising bans such as mass media, outdoor advertising, point-of-sale (POS) advertising materials, indirect advertising bans inducing brand stretching, brand sharing, and product placement, etc. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis study also supports the previous hypothesis that countries with high tobacco industry interference have more problems with tobacco use or smoking epidemics (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The sabotage strategy from the tobacco industry weakens the MPOWER package and national tobacco control level. Our study results showed that tobacco industry’s activities increased the population's tobacco consumption, confirming that the tobacco industry might be a primary facilitator of the tobacco epidemic. Meanwhile, tobacco use can be explained as the tobacco user as a host, tobacco product as an agent, and policy or media as an environment (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Eliminating tobacco industry from health policy design might be the most effective measure that governments can adopt to protect tobacco control activities, thereby averting the number of deaths and diseases caused by the tobacco epidemic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe results show that the tobacco industry's influence on the smoking prevalence rate is more significant for males than females. Given the smoking epidemic in women generally lagging behind men by 30–40 years (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), it is expected that smoking among women will increase first among those with higher socioeconomic status, as it did with men several decades prior, and a gap between gender will continue to narrow (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In this context, tobacco business activities could impact the increase in the smoking rate for both sexes.\u003c/p\u003e\u003cp\u003eOne of the strongest indicators of conflict of interest is whether the government owns the tobacco companies through weak tobacco control in SOTCs such as low tax rates, no indoor smoking restrictions, sales tobacco products to youth, and loose advertising regulations, etc. (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) Countries in which the government monopolizes the production and sales of tobacco products or owns at least one tobacco company must have a high TIII score based on a conflict of interest. Contrary to expectation, the TIII scores were not significantly higher in SOTCs. One possible reason based on economic theory might be that tobacco company monopolies lack competitive incentives to actively engage in sales tactics such as mass advertising and encouraging sales to youth and women. The other possible reason is the small sample size for countries with SOTCs.\u003c/p\u003e\u003cp\u003eSome limitations that need to be considered when interpreting the results. First, our findings from the 30 selected countries may not be generalizable to a wider pool of countries. Second, measurement errors need to be considered. Random measurement error in the exposure variable will bias associations towards the null (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Previous studies have used TIII as an exposure variable. In a study that evaluated the degree of FCTC 5.3 implementation in seven Asian countries using the TIII, the scoring system was designed with the help of tobacco control experts and validated through focused group discussion (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Hoe et al. have argued that one of the most cited barriers to tobacco control policy implementation around the world is tobacco industry interference, while TIII 2019 showed that adherence to Article 5.3 had been far from satisfactory worldwide (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Jeffrey Drope et al. found strong evidence that interference in tobacco control policymaking has increased in some countries in Latin America with the assessment results using the TIII 2020 (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAs the national compliance with the FCTC decreased, prevalence rates for adult daily smokers of tobacco increased if the interference of the tobacco industries was high. Tobacco industry tactics have been evolving to promote and grow tobacco businesses. Thus, it is crucial to resist tobacco industry disturbances to protect public health and save lives from harmful use of tobacco. Governments and global society should counter against tobacco industry interference to protect public health and advance tobacco control policies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTIII (Tobacco Industry Interference Index)\u003c/p\u003e\u003cp\u003eGGTC (Global Center for Good Governance in Tobacco Control)\u003c/p\u003e\u003cp\u003eWHO (World Health Organization)\u003c/p\u003e\u003cp\u003eFCTC (Framework Convention on Tobacco Control)\u003c/p\u003e\u003cp\u003eDALYs (Disability Adjusted Life Years)\u003c/p\u003e\u003cp\u003eSOTCs (State Owned Tobacco Companies)\u003c/p\u003e\u003cp\u003eTAPS (Tobacco Advertising Promotion and Sponsorship)\u003c/p\u003e\u003cp\u003eCSR (Corporate Social Responsibility)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePublicly available data are used in the study. All data relevant to the study are provided with the sources in the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJO and YL conceived the study. YL curated data and did the formal analysis. JO led the investigation and designed the methodology. SK and YL validated the data. YR wrote the original draft. MK reviewed and edited the manuscript. IK and JO supervised the study. All authors reviewed, revised, and approved the manuscript. All authors had access to all the data in the study and had final responsibility for the decision to submit for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the Global Center for Good Governance in Tobacco Control (Bangkok, Thailand) who provided data for this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMurray CJ, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari M, Borzouei S. Global burden of 87 risk factors in 204 countries and territories, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. 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BMJ global health. 2019;4(6):e002078. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1136/bmjgh-2019-002078\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2019-002078\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrope J, Rodriguez-Iglesias G, Stoklosa M, Szklo A. (2022). Recent evidence on the illicit cigarette trade in Latin America. Rev Panam Salud Publica; 46, oct. 2022. Special Issue Tobacco Control. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.26633/rpsp.2022.111\u003c/span\u003e\u003cspan address=\"10.26633/rpsp.2022.111\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Impact of the subcomponents of the Tobacco Industry Interference (TIII) on MPOWER scores in 30 countries\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"518\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.52123552123552%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMPOWER Scores (2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"62.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco Industry Interference Index (2019)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.055\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.125\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003eParticipation in Policy Development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003eTobacco-related CSR Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Benefits to the Tobacco Industry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.527\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Forms of Unnecessary Interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.591\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003eConflict of Interest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.560\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003eTransparency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.882\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.47876447876448%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Preventive Measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.32046332046332%\"\u003e\n \u003cp\u003e-0.240*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.2007722007722%\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: P\u0026lt;0.05*\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. Impact of the Subcomponents of the TIII on Subcomponents of the MPOWER package in 30 countries\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1068\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.51219512195122%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.915572232645403%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.101313320825517%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.287054409005629%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.350844277673547%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eW(1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.849906191369605%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eW(2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.819887429643527%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.163227016885553%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.860788863109049%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.65661252900232%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.2645011600928076%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.004640371229698%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.65661252900232%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.65661252900232%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.612529002320185%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco Industry Interference Index\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(2019)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.766\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.019\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.193\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.793\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.078\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.738\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.023*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.854\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eParticipation in Policy Development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e-0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eTobacco-related CSR Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e-0.079\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.179*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.837\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eBenefits to the Tobacco Industry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.381\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.452\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.549\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eForms of Unnecessary Interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e-0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.892\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.681\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eConflict of Interest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.490\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.839-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.981\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.686\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003eTransparency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e-0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.754\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.326\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.647\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.082\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.267\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.439252336448597%\"\u003e\n \u003cp\u003ePreventive Measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.94392523364486%\"\u003e\n \u003cp\u003e-0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.046728971962617%\"\u003e\n \u003cp\u003e0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.4485981308411215%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\"\u003e\n \u003cp\u003e-0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.168224299065421%\" colspan=\"2\"\u003e\n \u003cp\u003e-0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.327102803738318%\"\u003e\n \u003cp\u003e0.707\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: P\u0026lt;0.05*. M contains monitoring tobacco use and preventive measures and\u0026nbsp;five attainment levels for each other components. P means protecting the population from cigarette smoke, such as designing non-smoking areas in public places. O indicates help to quit tobacco use, such as smoking cessation clinics or cessation call centers. W consists of packaging a health warning about the dangers of tobacco (W1) and implementing a non-smoking campaign for cigarette risk (W2). E summarizes advertising on tobacco ban, promotion and sponsorship. R means raising taxes on tobacco.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3. Impact of the Subcomponents of the TIII on Adult Daily Smoking Prevalence by Gender in 30 countries\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"707\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\" rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.567185289957564%\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdult daily smoking prevalence (2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.251231527093594%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoth Sexes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.004926108374384%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.74384236453202%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.004914004914005%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.164619164619165%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.97051597051597%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1990171990172%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.461916461916463%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.1990171990172%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco Industry Interference Index\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(2019)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.170*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.036\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.417*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.062\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.390\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003eParticipation in Policy Development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.060\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e0.463*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.868\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Tobacco-related CSR Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.772\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e3.099*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.534*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Benefits to the Tobacco Industry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.944\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e2.073*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Forms of Unnecessary Interaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e1.093*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.036\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.985\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003eConflict of Interest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.636\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.328\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e2.081\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003eTransparency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e1.264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.688*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.432814710042436%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Preventive Measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.062234794908063%\"\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.032531824611032%\"\u003e\n \u003cp\u003e0.346\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.193776520509195%\" valign=\"top\"\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.476661951909477%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.900990099009901%\" valign=\"top\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"74.82319660537482%\" colspan=\"9\" style=\"width: 99.8586%;\"\u003e\n \u003cp\u003eNote: P\u0026lt;0.05*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3021903/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3021903/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to investigate the impact of tobacco industry interference on the implementation and management of tobacco control and the tobacco epidemic using the Tobacco Industry Interference Index (TIII), and MPOWER\u0026mdash;a package of measures for tobacco control\u0026mdash;and adult daily smoking prevalence in 30 countries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe TIII was extracted from the Global Tobacco Industry Interference Index 2019 and Global Center for Good Governance in Tobacco Control (GGTC). MPOWER measures and adult daily smoking prevalence rate were extracted from the World Health Organization (WHO) report on the global tobacco epidemic 2021. We assessed the ecological cross-lagged association between TIII and MPOWER scores as well as between TIII and age-standardized prevalence rates for adult daily tobacco users.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eTobacco industry interference was inversely correlated with a country\u0026rsquo;s package of tobacco control measures (β=-0.088, P\u0026thinsp;=\u0026thinsp;0.035). The TIII was correlated with weaker warnings about the dangers of tobacco (β=-0.016, P\u0026thinsp;=\u0026thinsp;0.078) and lack of enforcement of bans on tobacco advertising promotion and sponsorship (β=-0.023, P\u0026thinsp;=\u0026thinsp;0.026). In turn, the higher the TIII, the higher the age-standardized prevalence of adult daily smokers of tobacco for both sexes (β\u0026thinsp;=\u0026thinsp;0.170, P\u0026thinsp;=\u0026thinsp;0.036). Adult daily smoking prevalence in males (β\u0026thinsp;=\u0026thinsp;0.417, P\u0026thinsp;=\u0026thinsp;0.004) were higher in countries where the tobacco industry received incentives that benefited its business.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhere the interference of the tobacco industries was high, national compliance with the Framework Convention on Tobacco Control (FCTC) was lower and prevalence of adult daily smokers higher. National governments and global society need to work together to minimize the tobacco industry\u0026rsquo;s efforts to interfere with tobacco control policies.\u003c/p\u003e","manuscriptTitle":"Association between Tobacco Industry Interference Index (TIII) and MPOWER measures and adult daily smoking prevalence rate in 30 countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-06-16 15:36:19","doi":"10.21203/rs.3.rs-3021903/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major Revision","date":"2023-07-21T18:28:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2023-06-22T21:44:38+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-14T17:16:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-09T10:24:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Globalization and Health","date":"2023-06-05T08:11:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"globalization-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"glah","sideBox":"Learn more about [Globalization and Health](https://globalizationandhealth.biomedcentral.com/)","snPcode":"12992","submissionUrl":"https://submission.nature.com/new-submission/12992/3","title":"Globalization and Health","twitterHandle":"@GHJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"484f15f2-dd34-4d62-bb56-758e23f47833","owner":[],"postedDate":"June 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-08T15:03:16+00:00","versionOfRecord":{"articleIdentity":"rs-3021903","link":"https://doi.org/10.1186/s12992-023-01003-x","journal":{"identity":"globalization-and-health","isVorOnly":false,"title":"Globalization and Health"},"publishedOn":"2024-01-03 15:01:04","publishedOnDateReadable":"January 3rd, 2024"},"versionCreatedAt":"2023-06-16 15:36:19","video":"","vorDoi":"10.1186/s12992-023-01003-x","vorDoiUrl":"https://doi.org/10.1186/s12992-023-01003-x","workflowStages":[]},"version":"v1","identity":"rs-3021903","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3021903","identity":"rs-3021903","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}