Interest groups , voluntary agreements and tobacco control in Ghana

The paper examines the role of tobacco interest groups in obstructing the adoption of tobacco control policies in developing countries using the interest groups and global advocacy network theories. Specifically, it combines expert interviews with review of secondary materials to examine the strategies to promote the adoption of a tobacco control law in Ghana. This study finds that the adoption of the voluntary agreements in Ghana created the enabling environment for the adoption of a tobacco control law by the National Parliament in 2012, in contradiction to the findings of studies conducted in western countries that concluded that voluntary agreements are ineffective tobacco control instruments.


INTRODUCTION
The shift of tobacco companies' activities to the developing countries since the 1970s has created a constant struggle between anti and pro-tobacco tobacco interest groups over the adoption of the tobacco control policy by individual countries in Africa.The increased tobacco activities in developing countries were necessitated by the adoption of tough tobacco control laws in some developed countries (WCTOH, 2000).This has led to high consumption of tobacco with an estimated projection that about 350 million tobacco-related deaths and health hazards may occur in the developing countries by 2030 if actions are not taken to prevent the current trend of tobacco consumption (WHO, 2008).For instance, research shows that out of about seven thousand chemical compounds tobacco smoke contains, close to seventy have been identified as cancer causing agents or toxic compounds that can cause diseases such as lung cancer, bronchitis and emphysema (Ali, 2012).The chemicals have also been identified as major sources of high gravity of cardiac diseases.This makes tobacco a substance that is extremely harmful to the health of both smokers and non-smokers.Additionally, it raises concern of a public health epidemic emanating from the consumption of tobacco products (Lopez et al., 1994).In an effort to avoid such a tobacco epidemic, anti-tobacco interest groups have intensified their tobacco control activities and campaigns for the adoption of policies to protect public health.The interest groups collaborate with nongovernmental organizations (NGOs) and intergovernmental organizations (IGOs) that share a similar passion to avoid the tobacco epidemic (Asare, 2009).On the contrary, the pro-tobacco interest groups that perceive the developing countries as safe havens for promoting their profit making activities are vigorously resisting the activities of the anti-tobacco interest groups.More specifically, the pro-tobacco interest groups use their attained political power to lobby policymakers against the adoption of laws that can have adverse effect on their business (Brenya, 2012c).In other scenarios, the tobacco companies and other groups affiliated to the companies promote the adoption of voluntary agreements such as tobacco control instruments instead of legally backed laws enacted by the National Parliament.These voluntary agreements are often tobacco control instruments consented by the tobacco companies and thus violators receive no punishments and compliance is based on the will of the parties to respect the law.
The agreements are mostly issued as directives of the Ministry of Health, which are often the governmental agencies that promote tobacco control in developing countries because of the health hazards of tobacco (Cairney et al., 2012).However, the impact of the voluntary agreements varies from country to country depending on the strength of the pro-tobacco interest groups, activities of tobacco control interest groups, the negotiating power of the Ministry of Health, and the direct involvement of policymakers in the tobacco business.In countries where policymakers are directly involved in the tobacco business, the policymakers often become the actors who resist the adoption of stricter tobacco control instruments.Also, the voluntary agreements are often not regarded as tobacco control instruments and vice versa.For instance, Ghana adopted several voluntary agreements, which were issued by the Ministry of Health as directives to control tobacco despite the active tobacco industry activities that thrived in the country for over fifty years (Table 1).The agreements were well respected and were significantly impacting as tobacco control instruments due to the activities of the tobacco control groups led by the Ministry of Health.
The success of the voluntary agreements as tobacco control instruments can also be attributed to the absence of policymakers who were directly involved in the tobacco business.The voluntary agreements created the enabling environment for the official passage of a tobacco control bill into law in 2012 because the bill attracted less resistance from the tobacco industry interest groups because of the environment created by the voluntary agreements.Using the global advocacy network and the interest group theories, this paper strives to examine the politics surrounding the adoption of a tobacco control law in Ghana.Specifically, it seeks to explain how the Brenya 103 tobacco control interest groups used the voluntary agreements as tobacco control instruments in the period before the passage of the tobacco law.It also examines the impact of the strategy on the subsequent adoption of the tobacco law in July 2012.Lastly, it assesses how useful the Ghanaian tobacco control strategy could be for tobacco control in other countries of the developing world.Methodologically, the paper records data from interviews with twelve tobacco control experts and NGOs.
The data are triangulated with other data obtained from the review of policy documents and reports from government officials, governmental and nongovernmental organizations and existing research materials.The selection of interview participants was based solely on their research and involvement in tobacco control activities of Ghana.Furthermore, the data collected through correspondences with the interviewees are cited as personal communications in the paper.Finally, the information of the interviewees was withheld to comply with the requirement of the Institutional Review Board of West Virginia University that approved the questions before they were used for the interviews conducted between July 2010 and March 2011.

Interest groups, global advocacy network and tobacco control
The interest groups theory is generally used to examine the politics of policy adoption because of how the groups promote their interest as public policy.Generally, the activities of the interest groups take several forms with the basic objective of promoting issues considered important to their members as public policy in a specific country (Ethridge and Handelman, 2004).The activities of interest groups place the groups in one organization, association, union or community such as farmers, medical/health, or traditional group to influence the design, adoption and implementation of policies to their desire (Brenya, 2011).The activities of interest groups thrive well in a pluralistic political system where competitions, bargains and compromises are the core features of their operations (Lijphart, 1999;Wilensky, 2002).While some groups operate within the domestic arena, others focus on the global level to promote the adoption of policies for addressing issues considered to be global problems.In such instances, several interest groups collaborate to promote issues by advocating for the adoption of measures to address what they project as a global problem.For instance, interest groups that are concerned with preventing a global tobacco epidemic have formed a global advocacy network to promote the tobacco control campaign (Farquharson, 2003).Farquharson (2003) identifies the global advocacy network as group of individuals with a shared discourse and beliefs.The network is made up of two types of

1948
Veterans returning from WWII brought some tobacco products to the Ghana and started to demand for tobacco products in the country.Subsequently, the British American Tobacco (BAT) partnered with local groups to establish a tobacco warehouse and began selling cigarettes imported into the country The Gold Coast Tobacco Company was established in Ghana Pioneer Tobacco Company was established to promote domestic tobacco leaf cultivation and manufacturing of cigarette and the official manufacturing of cigarettes began in the country.The Pioneer Tobacco Company took over Gold Coast Tobacco Company Nkrumah's government passed a law to take over tobacco marketing, but the private companies returned after the overthrow of his government in 1966 The government established the Ghana Tobacco Leaf Company in order to manage the marketing of tobacco products The Acheampong's government passed a law to take over ownership of private cigarette manufacturing and tobacco leaf companies.The government also established the International Tobacco Ghana to take over the marketing and production of all tobacco products in the country.The government issued directives to prohibit smoking in government facilities, offices, and public places, including restaurants and cinema centers.The Ministry of Health issued a directive to ban tobacco advertisements on TV, radio and the print media The Leaf Development Company was established in 1988 to produce tobacco leaf for the local market and to lay the basis of a future export industry The government privatized the International Tobacco Ghana Ghana Committee on Tobacco Control was established BAT merged with Meridian Tobacco Company and became the sole local manufacturer of tobacco products in Ghana.Ghana also signed the Lome, Togo Declaration on the Contribution of Parliamentarians to Tobacco Control in the African Region the same year Ghana joined Global Tobacco Surveillance System (GTSS) and the first national Global Youth Tobacco Survey (GYTS) was conducted to determine prevalence of tobacco among the youth The immediate Director General of Ghana Health Service complained about the painting of the Kaneshie market, the biggest market in Accra with BAT products, and this generated a national debate about tobacco control Ghana became a member of Quit and Win International Smoking Cessation Program and the Ghana National Tobacco Control Steering Committee (GNTCSC) was inaugurated the same year The National Tobacco Control Steering Committee drafted the first national tobacco control bill for approval by Cabinet.A demographic and a health survey was also conducted the same year to assess the prevalence of tobacco among adults in the country Ghana signed and ratified the Framework Convention Tobacco Control (FCTC) A second national GYTS survey was conducted to determine tobacco prevalence among the youth and the tobacco bill was re-drafted to reflect the FCTC provisions and sent to Cabinet for consideration The Ministry of Health issued another directive to ban smoking in all Ministry of Health facilities.In addition, the Ministry of Transportation issued a directive to ban smoking in public and private commercial transport including the Ghana Private Roads Transport Union (GPRTU) and Inter City Buses, and also on both domestic and international flights, transport, buildings, ports, and stadia.Ghana also chaired one of the committee meetings of the first session of the FCTC Conference of Parties held in Geneva.Lastly, the British American Tobacco closed down its manufacturing company and relocated to Nigeria.
The Ministry of Health issued another directive to compel all importers of tobacco products to register their products and comply with the Food and Drugs Board (FDB) regulatory requirements.In addition, the Ministry, the GNTCSC, and the Ghana Tourist Board reached voluntary agreement with owners of entertainment industry to create smoke free area for nonsmokers.Ghana also chaired one of the committee meetings of the second session of the FCTC Conference of Parties meeting held in Thailand.The GNTCSC instituted a five-year plan of action to control tobacco in the country the same year.

2008
The Ghana National Tobacco Control Steering Committee reached an agreement with importers requiring the importers to disclose the content of tobacco products to be imported into the country.Ghana Demographic Health Survey (GDHS) conducted another survey to determine national tobacco prevalence among the adults in the country 2009 GYTS conducted another national survey to determine tobacco prevalence among the youth in the country.The Ministry of Education also developed a School Health Education Policy to promote healthy lifestyles and prohibit the use of tobacco by children in educational complexes.In addition, the Ghana Food and Drug Board directed all tobacco imported into Ghana to have the approved health warnings and cover the required sizes 2010 Ghana hosted the Second Meeting of the Working Group of the FCTC on Article ( 17) and ( 18) The Ministry of Health issued additional directives to mandate the posting of no smoking signs on the premises of all health facilities to strengthens its effort to prevent tobacco smoking on health facilities 2012 The National Parliament unanimously passed a tobacco control law as part of the Public Health bill to protect public health.
groups that operate globally to promote their members' beliefs through the exchange of services and relevant information.The first are groups with instrumental goals such as those affiliated to the tobacco industry, focusing on profit making and seeking to protect the industry's economic interest.The second are groups such as the IGOs, NGOs, epistemic communities and individuals linked to the tobacco control network that are motivated by shared principled ideas or values to prohibit the hazards of tobacco.Often, interest groups affiliated with both groups compete for the control of policy adoption that favors the interest of their members because of the pluralistic environment that they operate in (Ethridge and Handelman, 2004).In such a scenario, the pro-tobacco interest groups prevent the adoption of tobacco control laws that will limit the activities of the tobacco companies and affiliated groups in any country.Alternatively, the anti-tobacco interest groups champion activities that promote the adoption of laws to prohibit the consumption of tobacco and its related health hazards.The success of each group is primarily based on how organized and well-resourced the groups are (Asare, 2009).This renders it virtually impossible for one group to dominate policymaking activities in a pluralistic policy system.Generally, the pro and anti-tobacco interest groups disseminate vital information and resources to protect their interest in certain areas.Typically, the aim of these groups is to influence government officials and bureaucrats to believe that there is a policy problem that can be addressed by the groups' policy proposals (Studlar, 2002).For instance, the anti-tobacco interest groups use scientific evidence to convince governmental officials of an epidemic associated with tobacco consumption and offer tobacco control ideas as new policy solutions to prevent the epidemic (Mamudu, 2005).Simultaneously, the pro-tobacco interest groups also project tobacco production and sales as activities that can help to address the issue of poverty and unemployment in countries where the companies have economic interests (Mamudu et al., 2009).Therefore, the two groups also use their affiliates to lobby policymakers to promote their objectives in a particular country.Often, the anti-tobacco interest groups use activists and local NGOs to put pressure on policymakers to adopt stricter tobacco control laws in order to protect public health in a specific country.Meanwhile, the pro-tobacco interest groups use farmers and tobacco industry workers to protest the adoption of such tobacco laws (Otanez et al., 2007).

Pro -tobacco activities in Ghana
Ghana's experience with tobacco dates back to the 1940s when the product was first introduced to the country by veterans returning from World War II (Owusu-Dabo et al., 2009).The veterans were exposed to tobacco through their service abroad.Consequently, they brought some with them in 1948 and also demanded for the tobacco products when they returned to Ghana.In response, BAT entered into alliance with local entities to sell imported tobacco products the same year.This ushered the country to engage in active tobacco industry activities for several years.For instance, tobacco manufacturing plants and leaf buying companies, including state-owned tobacco manufacturing and leaf buying companies, operated in the country for more than 50 years until the last tobacco manufacturing company closed its plant in 2006 (Owusu-Dabo et al., 2009;Wellington et al., 2011).The presence of the companies caused tobacco leaf farming to supply raw materials for the local cigarette manufacturing companies (Personal Communication, 2010).However, tobacco farming decreased after the last tobacco manufacturing plant closed down.Currently, tobacco farming is a small portion of the diverse agricultural sector and the product is primarily cultivated in the northern and middle belts of Ghana.
Statistically speaking, agriculture generally accounts for over 50% of the foreign earnings, 54% of the gross domestic product (GDP), and employs about 55% of the workforce (Oppong-Anane, 2001;Owusu-Dabo et al., 2009).However, the distribution or selling of tobacco is considered one of the least contributors to the GDP and foreign earnings of the country1 .For instance, in 2007, Ghana produced 2700 tons of tobacco and exported 2455 tons, and the tobacco export ranked 17 th of the total commodities exported that year (Wellington et al., 2011).The total tobacco cultivated in 2007 was 5,750 hectares of the WHO's tobacco region, which ranked 75 th in the global production of tobacco leaves (Wellington et al., 2011;ACS and WLF, 2009).Nonetheless, tobacco is a major source of income and employment for farmers in the regions where it is cultivated.In fact, the tobacco industry also serves as a source of employment for importers and traders who sell cigarette products in the country.As a result, Ghana's tobacco control effort for a long time was hindered by the Ministries of Agriculture and Finance on grounds that adopting stricter tobacco control measures may cause farmers and other workers to become unemployed, thus having a negative impact on the country's GDP (Personal Communication, 2010).
In spite of the fact that there has been no tobacco manufacturing plant physically located in the country since 2006, the pro-tobacco interest groups still played an influential role to prevent the adoption of strict tobacco control law for several years.Currently, tobacco companies such as the British American Tobacco and Embassy along with distributors and importers of cigarettes such as Market Direct and Target Link spearhead the tobacco industry activities in the country.The groups lobby policymakers to prevent the adoption of tobacco control law that can obstruct their businesses.For instance, the failure of the NPP government to pass the tobacco control bill drafted by the National Tobacco Control Steering Committee (NTCSC) in 2007 into law has been attributed to the visit of the President of British American Tobacco Company and his private discussion with the former President, Mr. J.A. Kufour during his second term in office (Personal Communication, 2010).

Anti-tobacco activities in Ghana
Ghana's experience with tobacco control precedes the creation of the Framework Convention on Tobacco Control (FCTC) protocol.In the 1980s, the government, through directives, adopted tobacco control instruments a decade before the international tobacco treaty was adopted in 2005 (Owusu-Dabo et al., 2010).In spite of the vibrant tobacco industry activities and the efforts of pro-tobacco interest groups to prevent the adoption of control laws in Ghana, the anti-tobacco interest groups have pushed for the adoption of tobacco control instruments.Their efforts led to the adoption of voluntary agreements as tobacco control instruments, which lasted until tobacco control legislation was passed by the National Parliament in July, 2012.
The physical location of tobacco manufacturing plants in Ghana from the 1940s to the 2000s and the vibrant activities of the tobacco companies within that period is often considered a blessing for tobacco control in the country for it made it feasible for anti-tobacco interest groups to demonize the tobacco companies as entities that were tactlessly interested in their profit-making activities at the expense of public health.Simultaneously, it could also be argued that the insignificant contributions of tobacco to the GDP and foreign earnings of the country may have also contributed to Ghana's success with tobacco control compared to other African countries.Ghana generally relies on different agricultural products as major contributors to its GDP, such as cocoa farming, which is a major source of agricultural employment (Oppong-Anane, 2001).Therefore, tobacco-control interest groups received less resistance for tobacco control than they would have received if the country had relied on tobacco such as Zimbabwe and Malawi, which receives over 70% of their foreign earnings from tobacco (Otanez et al., 2009).
Nevertheless, Ghana deserves to be commended for their successful use of voluntary agreements to control tobacco in the country until the formal adoption of tobacco control law in 2012.This is because the voluntary agreements are often considered to be weak tobacco control instruments in some developed countries (Studlar, 2004).The Ministry of Health of Ghana collaborated with domestic and international tobacco control organizations and interest groups to promote tobacco control by using voluntary agreements often issued as directives of the Ministry as tobacco control instruments.The effective activities of the tobacco control groups and their international partners such as the WHO, Global Youth Tobacco Survey (GYTS), International Development Research Center (IDRC), American Cancer Society (ACS), Bill and Melinda Gates and Bloomberg Foundations created an unfavorable environment for the tobacco companies in Ghana.
For instance, the closing down of the BAT tobacco manufacturing plant in Ghana is attributed to the unfavorable environment for operation created by the tobacco control activities in the country (Personal Communication, 2010).BAT was forced to relocate its plant to Nigeria where it felt that the environment for production was more favorable than in Ghana.Generally, the international tobacco control partners offer assistance to their domestic partners in the form of funding and capacity building training to organize campaigns and educational programs aimed at facilitating the adoption of comprehensive domestic tobacco control policy (Becker, 2010;IDRC, 2009).
For instance, the Bloomberg Foundation and Initiative offered a grant to the Vision for Alternative Development (VALD), a nongovernmental organization in Ghana to undertake a consolidated campaign for the implementation of FCTC Article 11 (pictorial warning) and also to promote the adoption of a strong national tobacco control bill in Ghana (Personal Communication, 2010).In addition, the WHO, through the tobacco free initiative, assists the country with the organization of the annual no tobacco day celebration every year.The event has been serving as a major means for educating the public about the harm tobacco poses in Ghana.The IDRC also offered assistance to Ms. Edith Wellington, the focal point person for tobacco control at the Ghana Health Service, for training on effective tobacco control strategies in Canada (Personal Communication, 2010).The aid of the organizations helped Ghana to adopt some voluntary agreements as tobacco control instruments, which furthermore created an environment that allowed for the eventual passage of the tobacco control bill into law.

Voluntary agreements as tobacco control instruments in Ghana
The analysis of the data indicates that Ghana made significant progress with the adoption of certain demand reduction measures as tobacco control instruments through its adoption of certain voluntary agreements (WHO, 2011).Using a scale and data from a previous study by the WHO, this research finds that the country made significant progress with the adoption of measures to reduce the demand of tobacco (Table 2).The original WHO 2011 study used the data reported by the country to the organization to develop indicators for estimating the status of tobacco control (WHO, 2011).
On the monitoring measure of the FCTC protocol, the original measure of the WHO study required a country to have data acquired in 2003 or later, that is representative of the whole population and is repeated every five years in order to be at the fourth level of the scale.Ghana is within the fourth ranking on the scale because it has data that was from at least 2003 and is representative of the entire population (WHO, 2011).The Global Youth Tobacco Survey was conducted in Ghana in 2000, 2005 and 2009 to assess tobacco use among the youths.In addition, a national demographic and health survey to determine tobacco prevalence among adults was conducted in 2003 and 2008.The indicator for the protection against secondhand smoke measure examines the number of public places that are completely smoke-free based on a six scale measure that requires all, or at least 90% of the public places to be completely smoke-free (WHO, 2011).Ghana has voluntary agreements that prohibit smoking in all government buildings, Ministry of Health facilities, ports and harbors, stadia, airports.Additionally, smoking in public and certain private transport as well as all domestic and international airlines is prohibited (Owusu-Dabo et al., 2010).The directives for smoke free environments in Ghana were implemented in the 1980s when the government administratively restricted smoking in all government facilities, offices, and public through the directives of the Ministry of Health.The Ministry of Health has continued to exercise its disdain towards smoking with the active involvement of other ministries that have issued similar administrative directives.For example, the Ministry of Education in 2009 established the School Health Education Policy, which encourages both child-friendly school environments and healthy lifestyles along with prohibiting tobacco consumption (MOH et al., 2010).
The policy of the Ministry was instituted by directives to prohibit smoking by school children and teachers within certain parameters of the school.Failing to abide by these directives requires academic institutions to administer severe punishments in order to ensure compliance with the policy (ibid).In addition, the Ministry of Transport issued a directive to ban smoking in public transports, ports, domestic and international flights and some private commercial transports such as the GPRTU and inter-city buses in 2006.The National Tobacco Steering Committee and the Ghana Tourist Board (GTB) were also able to reach an agreement with the hospitality industryrestaurants and hotels -to designate certain areas as smoke-free ones (Personal Communication, 2010).Recently, the Ministry of Health has issued another directive to mount no smoking signs on the premises of all health facilities to further reinforce its smoke free measures (GNA, 2011).Granted, the country still allows smoking in certain public places such as the market places and police stations, placing the country in the fourth level of the scale.
The measure on assistance to quit tobacco use was analyzed using a five-scale indicator that examines whether or not a country has a national quit line along with government-funded nicotine replacement therapy or smoking cessation programs.The evidence from available data designates Ghana as a category-four country.This is because Ghana is a member of the international "quit and win cessation program", a program that offers incentives for smokers to quit.The costs and incentives encouraging smokers to abandon their habits are covered by the Ministry of Health and the Ghana Health Service (Wellington, 2007).Unfortunately, however, the country does not have a national quit line for smokers to call if they want assistance to quit smoking.
The measure for warning about the dangers of tobacco complies with the product regulation and ingredient disclosure of the FCTC stipulated in Articles ( 9), ( 10) and ( 11), which requires parties to make an effort to test and disclose the contents of tobacco products.Also, parties are encouraged to promote compliance with the required health warnings for tobacco products to be imported into the country (WHO-FCTC, 2009).The indicator was based on a six-scale measure that determines if a country has rotational health warnings on its available cigarette packs, the position and size of these warnings if deemed present, and whether or not specific health warnings are written in all the major languages of the country or are in pictorial form.Ghana ranked within the fifth category due to its voluntary agreement requiring the importers of the cigarettes to register and disclose the contents of cigarettes to be imported into the country.The Ghana Food and Drugs Board (FDB), per the 2007 directives of the Ministry of Health, i mandates tobacco importers to register all tobacco products (MOH et al., 2010).By way of monitoring, the importers are required to complete a form in which they indicate the contents of the products to be imported into the country and also required to test the ignition propensity of cigarettes.
The forms issued to the importers clearly suggest the required contents of cigarettes to be imported into the country with the required health warnings to be written on the cigarette packs.Generally, the importers are obliged to carry one of three rotational sets of textual health warnings ii on both the front and back of each pack (VALD, 2010;MOH et al., 2010;Personal Communication, 2011).Since 2010, the Ghana Food and Drug Board has been enforcing a requirement ensuring that the size of the warning covers 50% of both the front and back of the pack and also be written in black and white (MOH et al., 2010).The warnings are also required to be visible, legible, and written in English, in order to ensure clarity (MOH et al., 2010;Personal Communication, 2011).Moreover, all retailers are required to display a common warning of the Ministry of Health at all point of sales (Personal Communication, 2011).In addition, the Minister of Health hinted that the FDB is considering implementing appropriate pictorial health warnings for tobacco packs (Personal Communication, 2011;MOH et al., 2010).The Northern Command of Custom, Excise and Preventive Services (CEPS), has, on certain occasions, seized and destroyed certain cigarettes imported into Ghana because the packs did not exhibit a clear, mandated warning indicating the harmful effect of smoking (Personal Communication, 2010;GNA, 2009).
The measure for enforcing a ban on tobacco advertising is also in compliance with the FCTC.This measure places restrictions on advertising, promotion and sponsorship, indicated by Article ( 13), requiring all parties to adopt a comprehensive ban for these tobacco-marketing activities.The measure is based on a five-scale indicator that examines if a country has a complete ban on all direct and indirect forms of tobacco advertising, promotion and sponsorship (WHO, 2011).Ghana ranked four on a fivescale category because the country has, since 1982, successfully banned all direct cigarette advertisements of any form within the media (Personal communication, 2011;MOH et al., 2010;Wellington et al., 2011).
In addition, the Ghana Food and Drug Board's requirements for the importation of tobacco products into the country bans tobacco advertising on billboards, vehicles, and transportation stations as well as on walls of building.The requirements also prohibit tobacco sponsorship for events, and the offer of promotional samples of cigarettes to under age children is outlawed as well.However, point-of-sale advertising, outdoor and billboard advertising, and tobacco sponsorship of certain events is allowed under stringent restrictions (MOH et al., 2010).For instance, the National Media Commission allows for smoking to be broadcasted on TV when it is meant for plot and character development (MOH et al., 2010).In addition, international tobacco sponsorship is allowed for certain international events such as the FIFA world cup.
The measure for raising taxes on tobacco products is based on FCTC measure indicated in Article ( 6), which admonishes the adoption of price and tax measures to reduce tobacco consumption by all cohorts of society.This instrument is considered effective because it is based on the belief that as excise taxes on tobacco increases, tobacco prices increase as well, rendering the product inaccessible to marginal smokers and those with limited income.The measure was based on a five-scale indicator requiring at least 75% or more of the cigarette prices as taxes (WHO, 2011).Ghana ranked within category four of a five-scale indicator for the tax measure due to the manner in which it increased excise taxes on tobacco products on several occasions in order to raise revenue (Personal Communication, 2010;2011).Ghana has a total of between 14-59% excise taxes as a proportion of cigarette prices (Mackay et al., 2012;MOH et al., 2010).
The government of Ghana imposed an import duty of a flat ad valorem rate of 140% of the Cost, Insurance, and Freight (CIF) value on cigarettes, but the rate was changed and replaced in 2007 with a varied excise tax system for different brands of cigarettes (MOH et al., 2010).However, the government re-adopted the pre -2007 rates in 2009 (MOH et al., 2010).In addition, the Ministry of Finance increased the import duty to 150% in 2011 (Personal Communication, 2011).Additional taxes on cigarettes in the country include a value added tax (VAT) of 12.5% and a health insurance levy (NHIL) of 2.5%, both of which are imposed on all goods (Wellington et al., 2011).Tobacco products also attract 0.5% levies of the Economic Community of West African States (ECOWAS), domestic export development, and investment funds (EDIF) (Wellington et al., 2011;MOH et al., 2010).Generally, the taxes imposed on cigarettes in Ghana have been intended for revenue, not as punitive measures to control tobacco consumption (Wellington et al., 2011).This explains why some tobacco control activists criticize the prices of cigarettes, asserting that they are still cheap in Ghana relative to countries such as Canada and the UK.As a result, they have been urging the government to increase taxes in order to deter smokers from smoking (VALD, 2010).Nonetheless, it cannot be denied that the tax increases so far could still serve the dual purpose of compelling marginal smokers to quit and increase the country's revenue.
This study also analyzed other measures of the FCTC that were not covered by the WHO 2011 study.One such measure is the Provision of Support for Economically Viable Alternatives covered by the Article (17) of the FCTC, which mandates parties to assist tobacco farmers and workers with economically viable alternative crops to grow and also provide jobs (WHO-FCTC, 2009).In Ghana, minimal efforts has been undertaken to provide alternative economic activities for tobacco farmers.Generally, the closure of the BAT manufacturing plant caused tobacco farming to decrease.In turn, the Ministry of Food and Agriculture (MOFA), with assistance from the World Bank, has been offering limited loans to farmers to undertake alternative farming activities (Personal Communication, 2011).However, the credits offered to the farmers are nominally small and fail to motivate Brenya 109 farmers to stop growing tobacco leaves completely.The credit often extended to the farmers is not enough for them to acquire large farming land or undertake mechanized farming (Personal Communication, 2011).As a result, farmers end up consuming their crops, which prevent them from selling some of their products for income.The farmers, nevertheless, are able to obtain enough income to buy food and sometimes save.Another measure examined is the education, communication, and public awareness on the consequences of smoking covered by Article (12) of the FCTC.This measure requires parties to adopt programs to promote effective and comprehensive education and public awareness on the harm associated with tobacco consumption.In addition, it educates the public on second hand smoking along with informing smokers about where assistance in terms of quitting can be obtained.This measure is perhaps the most undertaken in Ghana to educate the public on the dangers and consequences that smoking and tobacco poses to public health.The Ministry of Health uses the annual no tobacco day, celebrated on May 31, to educate the public about the harmful effects of tobacco consumption (MOH et al., 2010).
The Ghana Health Service also uses the quit and wins campaign to highlight the benefits of tobacco cessation and living a tobacco free lifestyle (Wellington, 2007).The Health Ministry also collaborates with other Ministries and governmental agencies to offer educative programs on tobacco control.For instance, the Ministry of Education of Ghana, with the assistance of the Ghana Health Service, offers educational programs on the harm of tobacco in schools.Pictorial information known as the smoker's body posters are distributed to schools to increase awareness of the dangers associated with smoking (MOH et al., 2010).In addition, local NGOs, some media groups, and tobacco control organizations periodically organize public education events on the negative effect of smoking on public health.NGOs such as VALD periodically organize programs to educate the public on the harm of smoking (VALD, 2010).
The measure for the establishment of a national coordinating mechanism for tobacco control provided by Article (5) of the FCTC that recommends establishing a focal point for tobacco control was also examined.The formation of a national coordinating mechanism for controlling tobacco is considered essential to an effective tobacco control program (WHO-FCTC, 2009).
As indicated earlier, the Ministry of Health spearheads tobacco control activities in the country.In 2002, a National Tobacco Control Steering Committee (NTCSC) was established and tasked with adopting the appropriate mechanism for controlling tobacco in the country (Wellington, 2007).The Parliament of Ghana also tasked the committee with the responsibility of drafting a tobacco control bill for passage into law.Subsequently, the committee produced the first tobacco draft bill in 2005 (Wellington, 2007).The bill was re-drafted in 2007 and incorporated into the Public Health bill that was passed into law by Parliament in July of 2012 (Wellington, 2007;Ali, 2012).Moreover, a tobacco control focal point has been established and located at the Research and Development Division (RDD) of the Ghana Health Service to coordinate the tobacco control activities of the country (MOH et al., 2010).

Impact of voluntary agreements as tobacco control instrument in Ghana
The general perception often presented by studies conducted in some developed countries is that voluntary agreements are not effective tobacco control instruments (Studlar, 2004;Cairney, 2007).In spite of this, the analysis of Ghana Tobacco Control Process shows that the voluntary agreements have played a significant role as a tobacco control instrument that has facilitated the adoption of a tobacco control law.For instance, as stated earlier, the last tobacco manufacturing plant in Ghana left the country in 2006 because of the tobacco control activities (Personal Communication, 2010;Owusu-Dabo et al., 2010).The activities of the tobacco control interest groups created an unfavorable environment for British American Tobacco Company, which forced BAT to close down its plant in the country.An interviewee indicated that: I met one of the top people in the BAT, who said to me that they folded up in Ghana largely because of the campaign that was going on to get people to stop smoking cigarettes and the use of other products.I was told that it was strategically more economical to send the manufacturing to Nigeria and import into the country 2 Other actions that were taken to decrease the consumption of cigarettes included the adoption of tobacco control instruments such as a tobacco-advertising ban and periodic campaigns focusing on the harm of cigarettes to the health of smokers (Personal Communication, 2011).This affected the purchase of cigarettes and made it uneconomical to continue cigarette production in the country.
In addition, the requirement for importers to disclose the contents of cigarette products was well respected and it aided in regulating importers' activities (Personal Communication, 2010).Not only did the imported cigarettes carry the stipulated health warnings, but the ignition propensities were tested to meet the required 2 Adopted from Brenya (2012b) standard.Notably, the actions of these anti-tobacco groups satisfy the objective of the supply side of the tobacco control measures -to control the activities of the tobacco industry (WHO-FCTC, 2009).On the demand side, 43.3% of participants who took part in the quit and win program stayed tobacco-free three years after the adoption of the program in 2002 (Wellington, 2007).Nonetheless, some surveys conducted in the country show that the majority of the people consider the tobacco issue as a public health issue as opposed to the political economy image that was presented by the tobacco industry in the past (Wellington et al., 2009).While a comprehensive analysis of the impact of these voluntary agreements was not the focus of this study, these indicators, to some extent, show the impact that voluntary agreements had in the country, especially on the supply side control measures.

Interest groups, global advocacy network and adoption of domestic tobacco control instruments
The passage of the Public Health bill, which has section six on tobacco control, was facilitated by the interactions and collaborations between the international, nongovernmental and governmental organizations and agencies along with local tobacco control groups (Hudson, 2001).The collaboration between the Ministry of Health and local NGOs assisted the adoption of certain voluntary agreements on tobacco control, thus providing an enabling environment for the passage of the tobacco control bill.The adoption of the voluntary agreements in Ghana has primarily been the result of the interactions between the Ministry of Health and anti-tobacco interest groups, along with the actions of transnational tobacco control actors at different tobacco control venues (Cairney et al., 2012).
Normally, the information regarding the best practices for enforcing tobacco control are presented to the countries at such meetings, and the countries proceed to adopt the ones that are relevant to their tobacco control situation (Mamudu, 2005).In other instances, the countries receive funding for the adoption of a specific instrument of tobacco control.The director of VALD was influential in pushing for the passage of the Public Health bill because VALD received funding from the Bloomberg Foundation to promote the adoption of pictorial warnings as a tobacco control instrument in Ghana.Consequently, the tobacco control section of the bill expends a significant portion on pictorial warnings (Ali, 2012).Therefore, it is reasonable to state that advocacy networks and the activities of interest groups influenced the adoption of tobacco control instruments in the country.
As indicated above, many of the voluntary agreements adopted through the directives of the Ministry of Health along with the increases in excise taxes on cigarettes in Ghana were influenced by the international non-governmental and governmental organizations and agencies.Such groups include the IDRC/RITC, the WHO, America Cancer Society, the International Union against Cancer (UICC), and the Framework Convention Alliance.These organizations champion the adoption tobacco control best practices and ideas such as implementing high excise taxes, health warnings, and placing bans on tobacco advertising and smoking in public places (Laugesen, 2000).For instance, the Ministry of Health issued a directive for smoke free areas to be designated at certain public places following the adoption of smoke free laws by conference of parties of the FCTC since 2007 (WHO-FCTC, 2009).
It needs to be indicated that the battle between protobacco and anti-tobacco interest groups over tobacco control is not only about the adoption or non-adoption of tobacco control laws but also about shaping an understanding of the tobacco issue.The interest groups affiliated with the tobacco industry want the issue to be perceived as that of political economy and, as a result, hope to project the economic importance of tobacco products on developing countries (Mamudu et al., 2008;WHO, 2008).On the other hand, the anti-tobacco interest groups refute the political economy argument, highlighting the negative health hazards of cigarette smoking on both smokers and non-smokers.The interest groups organize campaigns and educational programs to educate the public on the health hazards of tobacco consumption.As indicated above, the annual no tobacco day is a means used to demonstrate the dangers of smoking, ultimately pressuring policy makers to adopt relevant policies that will protect public health.The celebration is a form of symbolic politics, whereby the harm caused by tobacco consumption somewhere is emphasized to seek support for the adoption of tobacco control policy in the domestic arena (Keck and Sikkink, 1998).
In the past, the tobacco industry network was successful in informing a majority of countries about the economic importance of tobacco (WB, 1999).However, the World Bank's 1999 groundbreaking study has rejected the tobacco industry's claim regarding the economic importance of tobacco for the development of developing countries.Simultaneously, the findings from other studies have provided evidence demonstrating the harm associated with tobacco consumption.As a result, the general understanding has shifted towards a support for tobacco control laws that protect public health (Mamudu et al., 2008;WHO, 2008).A recent survey conducted in one of the main tobacco growing areas in Ghana indicates a willingness of farmers to grow alternative crops due to the negative health hazards associated with tobacco leaf farming (IDRC, 2009).
In addition, another survey found massive support among the public for the adoption of stricter tobacco control policies, aiming primarily to prevent the sales of cigarettes to minors and to enforce a total ban of smoking Brenya 111 in public places (IDRC, 2009).One of the surveys, which were conducted by Ms. Edith Wellington of the Ghana Health Service and three other colleagues, had a total participation count of 308 people, and included members of Parliament and other policy makers.To gather data, the survey used questionnaires on 242 participants and in-depth interviews of 66 participants (IDRC, 2009).The survey found that the majority of Ghanaians were concerned with the problem of tobacco consumption and its health hazards, especially those posed on the youths.
In another instance, the Chairman of the Parliamentary Select Committee on Health and the Minister of Local Government and Regional Development in 2009 called for the immediate passage of the tobacco control bill into law to protect public health and to prevent the negative impacts of tobacco smoke on nonsmokers (Odoi-Larbi, 2009).Tobacco control experts and activists indicated that the change in policymakers' attitudes and the recent public support in terms of tobacco control policies were the result of the existing tobacco control information and educational programs (Personal Communication, 2011).Some of the people interviewed agreed that the current interpretation of the tobacco issue as a public health issue by the public is due to the messages that the public has been receiving from tobacco control actors and programs.It is generally believed that a change in the understanding of the tobacco issue was a necessary precursor to the adoption of tobacco control legislation.Therefore, it was the campaign and advocacy activities of the antitobacco interest groups in collaboration with international partners that generated support for the adoption of the tobacco control law in Ghana.

Conclusion
The analysis above provides insight into the politics surrounding the adoption of tobacco control policies in Ghana, focusing on how tobacco control interest groups have collaborated with international governmental and nongovernmental organizations to advocate for the adoption of a tobacco law in the country.Previous studies have shown how international governmental and nongovernmental actors collaborate with actors to ensure the adoption of a certain policy (Asare, 2009;Keck and Sikkink 1998;Farquharson, 2003;Hudson, 2001, Trubek et al, 2000, Mamudu and Studlar, 2009).For example, a research by Keck and Sikkink (1998) found that international NGOs and governmental actors collaborated to push for the adoption of laws to abolish slavery and to protect human rights and women's rights in certain countries at different periods.
In addition, a study by Malan and Leaver (2003) found that the success of South Africa's tobacco control was partly due to the pressure from anti-smoking groups and nongovernmental organizations on policymakers to adopt domestic tobacco control laws.Asare (2009: 103) identifies some of the anti-smoking groups in South Africa as the National Council against Smoking (NCAS), the South African Medical Research Council (SAMRC), the Cancer Association of South Africa (CANSA), the Heart and Stroke Foundation of South Africa (HSFSA).Asare (2009) indicates that the antitobacco groups in South Africa collaborated with intergovernmental and nongovernmental organizations such as the WHO, World Heart Federation, International Union against Cancer, and the World Conference on Tobacco or Health, (WCTOH) to ensure the success of the tobacco control campaign.Asare (2009) along with Malan and Leaver (2003) note that the groups lobbied persistently, waging a relentless war to protect both smokers and nonsmokers from the harm of tobacco before government intervention in the 1990s.Furthermore, they argue that the lobbying, combined with the subsequent commitment to public health by the African National Congress government led by Nelson Mandela, resulted in the adoption of a tobacco control law in South Africa.According to Waverly (2007), it was the collaborations between the domestic and international tobacco control actors that helped South Africa control the consumption of tobacco products despite the strong opposition from the tobacco companies and interest groups.
This study illustrates how international governmental and nongovernmental organizations have actively collaborated with domestic tobacco control interest groups in Ghana to push for the adoption of a tobacco control law in the country despite the vibrant tobacco industry activities occurring simultaneously.This study argues that the activities of the tobacco control interest groups and organizations led to the adoption of certain voluntary agreements as tobacco control instruments through the directives of the Ministry of Health (and other government ministries in Ghana) in the face of opposition by the tobacco industry network.The adoption of the voluntary agreements as tobacco control instruments weakened the influence of the pro-tobacco interest groups, creating a favorable environment for the subsequent adoption of a tobacco control law in the country.Consequently, the tobacco industry interest groups were incapable of resisting the passage of the Public Health bill, which declares tobacco control in the sixth section of the bill as a law.Therefore, Ghana's strategy could be a model for other developing countries who are struggling with adopting tobacco control policies and its related hazards to utilize.

Table 1 .
Timeline of tobacco production and control efforts in Ghana.

Table 2 .
Status of policies and progress towards selected demand reduction tobacco control measures.