Lee, W. R. (1973).British Journal of Industrial Medicine,30, 118-124. Emergence of occupational medicine in Victorian times. The events surrounding the establishment and development of legislation to protect the health of people at work in Victorian times are already well documented. This paper deals with some other aspects of the development of occupational medicine.
Medical opinions at the time did not always see the misuse of child labour as due simply to avaricious mill owners, but in part due to the parents and in part to the workmen subcontractors. The establishment of the certifying surgeons is briefly reviewed and their coming together to form an association in 1868 may be related to questions about the need for medical certificates of age which were being requested by the many factory owners brought under factory legislation for the first time in 1864 and 1867.
The plight of injured workmen and their dependents was early recognized, although it was late in the Victorian era before any statutory provision was made for them. The idea of linking compensation with preventive measures came to the fore in 1845 when some Manchester doctors, later supported by Edwin Chadwick, examined the workings at the Woodhead railway tunnel across the Pennines. When compensation legislation was passed some half a century later the idea was lost, and to this day compensation for and prevention of industrial injury and disease remain separated.
The change of industrial diseases from a medical curiosity to a problem requiring State intervention is traced over the latter part of the Victorian era.
The whole piecemeal pattern illustrating the precept that `social problems come first, social philosophy after' has persisted until the far-reaching changes in health and safety legislation of the present day.
Industrial medicine saw its tentative beginnings among the inquiring minds of 16th century physicians such as Paracelsus. In the 17th century, reports of conditions in mines on the Continent prompted natural scientists at the Royal Society to initiate a research programme into what we now know as mercurial poisoning. The latter part of the eighteenth century witnessed the change from domestic to factory industry with its concomitant social, economic, and technological upheaval, resulting in great shifts of population away from the countryside to the towns. Men, women, and children were employed in the new factories in primitive, unhygienic conditions, and mill fever and illness generally were rife. It was against this background that Percival and Thackrah, prompted no doubt in large measure by the conditions of child labour, inquired into, and made recommendations for, the improvement of hygiene in the factories, thus laying the foundations of industrial medicine as we know it today.
This report outlines the content of a one-day workshop on Generic Medicines that was held at KIST Medical College, Lalitpur, Nepal on 13th December 2010, which was attended by 32 delegates from different institutions in Nepal, including pharmacists, pharmacologists and medical doctors. Right medicine, right patient, right dose, right frequency and duration, right information and right monitoring are conditions to be fulfilled for the rational use of medicine (RUM). The World Health Organization (WHO) defines generic medicine as ‘a pharmaceutical product, usually intended to be interchangeable with the innovator product, marketed after the expiry of patent or other exclusivity rights’. Economic factors, supportive legislation and regulation, public and professional acceptance and quality assurance are key enabling factors promoting use of generics. Increased patent protection for medicines and removing process patents is a key feature of new trade agreements and newer medicines for diseases like HIV/AIDS, tuberculosis and infectious diseases are likely to be more expensive. The Medicine and Therapeutics Committee (MTC) can play a key role in promoting generic medicine use in institutions.
Nepal being among the Least Developed Countries (LDCs) need not provide patent protection for medicines until 31st December 2015. Only a few ‘true’ generics are available in Nepal and there is huge cost variation in the price of different branded generics. Clinicians have concerns about the quality of medicines in general, substitution of poor quality brands by pharmacists and about therapeutic substitution. Generics have to meet the same regulatory requirements and be bioequivalent to reference preparations assuring their quality.
Generic medicines; Nepal; Patents; Rational use of medicines
In the 1930s in Britain, industrial medicine was a clinical discipline, the main purposes of which were to diagnose disability in applicants for work, to identify industrial disease in the dangerous trades, and to provide first aid treatment for those injured or taken sick in the workplace. Following rapid developments in epidemiology and occupational hygiene and with more emphasis on "group health" and less on "individual care", occupational medicine has tended to become less of a clinical discipline; yet clinical skills are needed to assess fitness for work, to identify adverse effects of work, and to undertake consultations on a variety of health problems. Although care of the individual worker is a major task, an occupational health service has a responsibility for the health of the workforce as a whole, using epidemiology to plan and administer health care, to identify and control work related disorders, and to promote health by identifying positive factors in the organisation that induce a sense of well being; and by health screening and education programmes. Academic occupational health should not lose its identity as a clinical discipline in any merger with environmental health. Medical skills are needed to assess fitness for work and to identify human responses to adverse factors in the environment and to evaluate control measures.
This article outlines how the tobacco industry has undermined tobacco control efforts in Lebanon since the early 1970s.
An analysis of online and on-site tobacco industry documents, reviews of newspapers, policy and other documents, and interviews with key policy makers were conducted.
Findings reveal how the weakness of tobacco control legislation in Lebanon has been the product of an effective tobacco industry strategy to weaken the content and scope of regulation, and delay adoption and implementation.
The tobacco industry has built and maintained strong alliances that were and are regularly mobilised to effectively oppose regulation. Despite ratification of the World Health Organization Framework Convention on Tobacco Control in 2005, Lebanon's tobacco control track remains weak. Public health professionals and the government should work hard to oppose such tobacco industry tactics.
A diverse range of human diseases, including allergy, asthma, autoimmune disease, cancer and chronic neurologic diseases, notably multiple sclerosis and endogenous depression, is becoming more prevalent in industrialized countries. It has been postulated that environmental factors associated with improved standards of hygiene play a leading role in this process since the immune system seems to need extrinsic challenges for its proper maturation.
The inner world
An added dimension has now emerged—the impact on disease of the inner world, principally the numerous endogenous retroviruses (HERVs) within the human genome. Taking melanoma as an example, we propose a framework for understanding how a complex infectious and immunological background can induce or inhibit expression of a HERV-related disease process. The central role of a failure to induce or to maintain certain populations of self-specific CD8+ T-cells mediating immune surveillance, the expression of HERV-encoded peptides on affected cells and pathological mechanisms directly attributable to HERV proteins are discussed.
The presented concepts explain events preceding the clinical manifestation of diseases by several years and provide a rationale for the use of currently available vaccines to protect against certain HERV-induced diseases, especially melanoma. Criteria for establishing the causal role of HERVs in a given disease are proposed.
Melanoma; Hygiene hypothesis; HERV; Immune repair; Koch postulates
There is growing interest in the field of occupational medicine concerning employee health. This interest has been prompted by responsible corporate management as well as to the passage of Federal Legislation. An Occupational Health Information System (OHIS) has been developed to perform data base management functions for tracking employee health. OHIS is comprised of 3 modules which contain personnel, medical, and industrial hygiene/toxicology information. Each module contains information which is integrated into one data base. A dictionary system defining all possible data elements provides powerful analysis and reporting of selected data keys. The present system not only enhances health care delivery by virtue of its reporting and data management capabilities, but provides powerful data analysis capabilities which are otherwise impossible by manual recordkeeping systems.
According to official statistics, the rate of occupational accidents (OAs) and fatal injuries in Russia decreased about 5-fold and 2-fold, respectively, from 1975 to 2010, but working conditions during this period had the opposite trend; for example, the number of people who work in unfavourable and hazardous conditions (particularly since 1991) has increased significantly.
This review summarises the results of a search of the relevant peer-reviewed literature published in Russia and official statistics on OAs and occupational safety in Russia and the Russian Arctic in 1980–2010.
The occupational safety system in Russia has severely deteriorated in the last 2 decades, with legislators tending to promote the interests of industry and business, resulting in the neglect of occupational safety and violation of workers’ rights. The majority of workers are employed in conditions that do not meet rules of safety and hygiene. More than 60% of OAs can be attributed to management practices – violation of safety regulations, poor organisation of work, deficiency of certified occupational safety specialists and inadequate personnel training. Research aimed at improving occupational safety and health is underfunded. There is evidence of widespread under-reporting of OAs, including fatal accidents. Three federal agencies are responsible for OAs recording; their data differ from each other as they use different methodologies. The rate of fatal OAs in Russia was 3–6 times higher than in Scandinavian countries and about 2 times higher compared to United States and Canada in 2001. In some Russian Arctic regions OAs levels are much higher.
Urgent improvement of occupational health and safety across Russia, especially in the Arctic regions, is needed.
occupational accidents; injuries; fatal accidents; occupational safety; labour conditions; Russian Arctic
Hygiene inspections on passenger ships are important for the prevention of communicable diseases. The European Union (EU) countries conduct hygiene inspections on passenger ships in order to ensure that appropriate measures have been taken to eliminate potential sources of contamination which could lead to the spread of communicable diseases. This study was implemented within the framework of the EU SHIPSAN project and it investigates the legislation applied and practices of hygiene inspections of passenger ships in the EU Member States (MS) and European Free Trade Association countries.
Two questionnaires were composed and disseminated to 28 countries. A total of 92 questionnaires were completed by competent authorities responsible for hygiene inspections (n = 48) and the creation of legislation (n = 44); response rates were 96%, and 75.9%, respectively.
Out of the 48 responding authorities responsible for hygiene inspections, a routine programme was used by 19 (39.6%) of these to conduct inspections of ships on national voyages and by 26 (54.2%) for ships on international voyages. Standardised inspection forms are used by 59.1% of the authorities. A scoring inspection system is applied by five (11.6%) of the 43 responding authorities. Environmental sampling is conducted by 84.1% of the authorities (37 out of 44). The inspection results are collected and analysed by 54.5% (24 out of 44) of the authorities, while 9 authorities (20.5%) declared that they publish the results. Inspections are conducted during outbreak investigations by 75% and 70.8% of the authorities, on ships on national and international voyages, respectively. A total of 31 (64.6%) and 39 (81.3%) authorities conducted inspections during complaint investigations on ships on international and on national voyages, respectively. Port-to-port communication between the national port authorities was reported by 35.4% (17 out of 48) of the responding authorities and 20.8% (10 out of 48) of the port authorities of other countries.
This study revealed a diversity of approaches and practices in the conduct of inspections, differences in the qualifications/knowledge/experience of inspectors, the legislation applied during inspections, and the lack of communication and training among many EU countries. An integrated European inspection programme involving competent expert inspectors in each EU Member States and special training for ship hygiene delivered to crew members and inspectors would help to minimize the risk of communicable diseases. Common inspection tools at a European level for hygiene inspection practices and port-to-port communication are needed.
Max von Pettenkofer (1818–1901) belonged to the scientific elite of the 19th century. With his stringent search for the laws of nature and his fight for scientific truth, Pettenkofer was the prototype of a modern researcher. In the field of hygiene, he sought ways and means of preserving health and preventing sickness. With his consistent application of the experimental method to the field of public health, Pettenkofer helped the discipline of hygiene to provide precise and reliable answers to sanitary questions. In his experimental work on hygiene, Pettenkofer sought an answer to every imaginable question concerning the connection between the human organism and its environment.
To proceed in this direction, Pettenkofer combined medical expertise with physics, chemistry, technique and statistics. This even today modern “crossover-thinking” made hygiene to the first interdisciplinary medical field. With his Institute of Hygiene, Pettenkofer established 1879 the first centre of competence for hygiene and environment in the world, opening a new era of environmental observation.
In the framework of hygiene, Pettenkofer turned also to questions of nutrition and the quality of foodstuff. The science of hygiene owes to Max von Pettenkofer not only its development and cartography, but also its introduction as an academic discipline. Finally he regarded hygiene also as an economic and cultural feature. His idea about a clean soil in the cities and his promotion of adequate water supply and sufficient sewage networks are linked to his theory of the cholera. Pettenkofer believed that a battle against this epidemic could be won.
Max von Pettenkofer; Japan; hygiene; cholera; preventive medicine
In new legislation for paediatric medicines which came into effect on 26 January 2007, the European Union (EU) has attempted to address several unresolved issues relating to children's needs for medicines in Europe. This article reviews the legislation's main proposals and makes some comparisons with equivalent legislation in the USA. We argue that the legislation suffers from several gaps and uncertainties in relation to the specific proposals and their intended aims. As the establishment of new legislation in this area offered the EU an opportunity to set some clear guidelines and objectives, and had the potential to go beyond the equivalent American rules, we thus see the proposals as something of a disappointment.
European Union; paediatric medicines policy; legislation; research incentives; obligations
Molecular medicine is transforming everyday clinical practice from an empirical art to a rational ortho-molecular science. The prevailing concept in this emerging framework of molecular medicine is a personalized approach to disease prevention, diagnosis, prognosis, and treatment. In this mini-review, we discuss the educational and social-ethical issues raised by the advances of biomedical research as related to medical practice; outline the implications of molecular medicine for patients, physicians, and researchers; and underline the responsibilities of academia and the pharmaceutical industry to translate the scientific knowledge to a meaningful improvement of the quality of life across all members of society.
PLoS Medicine editors outline three journal policies that they believe help to break a "cycle of dependency that has formed between journals and the pharmaceutical industry."
The aviation domain provides a better analogy for the "temporary" teams that are found in acute medical specialities than industrial or military teamwork research based on established teams. Crew resource management (CRM) training, which emphasises portable skills (for whatever crew a pilot is rostered to on a given flight), has been recognised to have potential application in medicine, especially for teams in the operating theatre, intensive care unit, and emergency room. Drawing on research from aviation psychology that produced the behavioural marker system NOTECHS for rating European pilots' non-technical skills for teamwork on the flightdeck, this paper outlines the Anaesthetists Non-Technical Skills behavioural rating system for anaesthetists working in operating theatre teams. This taxonomy was used as the design basis for a training course, Crisis Avoidance Resource Management for Anaesthetists used to develop these skills, based in an operating theatre simulator. Further developments of this training programme for teams in emergency medicine are outlined.
In silico models have prompted considerable interest and debate because of their potential value in predicting the properties of chemical substances for regulatory purposes. The European REACH legislation promotes innovation and encourages the use of alternative methods, but in practice the use of in silico models is still very limited. There are many stakeholders influencing the regulatory trajectory of quantitative structure-activity relationships (QSAR) models, including regulators, industry, model developers and consultants. Here we outline some of the issues and challenges involved in the acceptance of these methods for regulatory purposes.
Research models and regulatory measures could aid in developing antimicrobial drugs to address bacterial resistance.
Innovative regulatory and legislative measures to stimulate and facilitate the development of new antimicrobial drugs are needed. We discuss research approaches that can aid regulatory decision making on the treatment of resistant infections and minimization of resistance selection. We also outline current and future measures that regulatory agencies may employ to help control resistance and promote drug development. Pharmacokinetic/pharmacodynamic research models offer promising approaches to define the determinants of resistance selection and drug doses that optimize efficacy and reduce resistance selection. Internationally, variations exist in how regulators use drug scheduling, subsidy restrictions, central directives, educational guidelines, amendments to prescribing information, and indication review. Recent consultations and collaborations between regulators, academics, and industry are welcome. Efforts to coordinate regulatory measures would benefit from greater levels of international dialogue.
Antibiotic resistance; Bacterial infections; Clinical trials; Drug approval; Drug industry; Drug resistance, microbial; Outcome assessment; Pharmacology; Pharmacokinetics
Smiley, J. A. (1971).Brit. J. industr. Med.,28, 315-322. Some aspects of the early evolution of the Appointed Factory Doctor Service. The appointment of certifying surgeons marks the beginning of the recognition by the State of its responsibility for the supervision of the health and welfare of young people in industry. The importance of the rôle played by Leonard Horner, one of the first four inspectors of factories, is discussed. Some of the problems and vicissitudes of the service in the 19th century are outlined and it is suggested that the system is inappropriate to the needs of the present. Legislation which would integrate all the agencies which are concerned with the well-being of young people, including the Appointed Factory Doctor Service, should be actively considered.
Objective: To outline a novel strategy for controlling the tobacco market.
Arguments: More comprehensive controls over the tobacco market are essential and long overdue. Effective controls need to encourage the development of less harmful products; control commercial communication to ensure that potential harms are highlighted relative to any benefits; and provide mechanisms to move consumers away from tobacco use, or at least towards less harmful alternatives. Achieving this by regulating the existing industry is one strategy. This paper puts the case for an alternative: to have marketing controlled by an agency (called here the Tobacco Products Agency, or TPA) which tendered to manufacturers for product and which distributed to retailers in ways that reduce incentives to bend or break the law. The TPA would be backed by legislation that made tobacco a controlled substance with possession sale and use only allowed as permitted by the regulations, which in reality would be only as provided by the TPA.
Conclusions: The overall effect of such a model, which we call a "regulated market model", would be to eliminate most of the incentives and remaining opportunities for commercial promotion of tobacco and to create incentives to encourage the development of less harmful tobacco products. Such a model preserves the competition inherent in a free market, but directs it towards the challenge of reducing the harm from tobacco use.
In September 2003, the Canadian government committed to developing legislation that would facilitate greater access to affordable medicines for developing countries. Over the course of eight months, the legislation, now known as Canada's Access to Medicines Regime (CAMR), went through a controversial policy development process and the newspaper media was one of the major venues in which the policy debates took place. The purpose of this study was to examine how the media framed CAMR to determine how policy goals were conceptualized, which stakeholder interests controlled the public debate and how these variables related to the public policy process.
We conducted a qualitative content analysis of newspaper coverage of the CAMR policy and implementation process from 2003-2008. The primary theoretical framework for this study was framing theory. A total of 90 articles from 11 Canadian newspapers were selected for inclusion in our analysis. A team of four researchers coded the articles for themes relating to access to medicines and which stakeholders' voice figured more prominently on each issue. Stakeholders examined included: the research-based industry, the generic industry, civil society, the Canadian government, and developing country representatives.
The most frequently mentioned themes across all documents were the issues of drug affordability, intellectual property, trade agreements and obligations, and development. Issues such as human rights, pharmaceutical innovation, and economic competitiveness got little media representation. Civil society dominated the media contents, followed far behind by the Canadian government, the research-based and generic pharmaceutical industries. Developing country representatives were hardly represented in the media.
Media framing obscured the discussion of some of the underlying policy goals in this case and failed to highlight issues which are now significant barriers to the use of the legislation. Using the media to engage the public in more in-depth exploration of the policy issues at stake may contribute to a more informed policy development process. The media can be an effective channel for those stakeholders with a weaker voice in policy deliberations to raise public attention to particular issues; however, the political and institutional context must be taken into account as it may outweigh media framing effects.
Objective: To examine the tobacco industry's efforts to influence public policy and block the legislative process on tobacco control in Hong Kong, 1973 to 1997.
Method: Systematic review of relevant tobacco industry documents made public via the Master Settlement Agreement.
Results: The tobacco industry in Hong Kong has sought to manipulate the policymaking process and delay the introduction of tobacco control legislation in Hong Kong from at least 1973. The industry ensured that each of the government's initial meagre steps toward tobacco control were delayed and thwarted by drawn out "cooperation" followed by voluntary concessions on issues the industry regarded as minor. By the 1980s the government had became increasingly active in tobacco control and introduced a number of initiatives, resulting in some of the tightest legislative restrictions on smoking in Asia. The tobacco industry was successful in thwarting only one of these initiatives.
Conclusions: Throughout the 1980s and 1990s two factors played a significant role in hindering the tobacco industry from successfully blocking policy initiatives: a growing political imperative, and an active and sophisticated tobacco control movement. Political will to promote public health and a strong tobacco control advocacy presence can enable governments to resist the enormous pressure exerted upon them by multinational tobacco companies.
The National Health Insurance Scheme (NHIS), and the National Identification Authority (NIA), pose ethical challenges to the physician-patient relationship due to interoperability. This paper explores (1) the national legislation on Electronic Health Information Technology (EHIT), (2) the ethics of information technology and public health and (3) the effect on the Physician-patient relationship.
This study consisted of systematic literature and internet review of the legislation, information technology, the national health insurance program, and the physician-patient relationship.
The result shows that (1) EHIT have eroded a big part of the confidentiality between the physician and patient; (2) The encroachment on privacy is an inevitable outcome of EHIT; (3) Legislation on privacy, the collection, storage and uses of electronic health information is needed and; (4) the nexus between EHIT, NHIS, NHA, Ethics, the physician-patient relationship and privacy.
The study highlights the lack of protection for physician-patient relationship as medical practice transitions from the conventional to the modern, information technology driven domain.
Physician-patient Relationship; Legislation; Public Health; National Health Insurance Scheme; National Identification Authority; Electronic Health Information
OBJECTIVE: To determine state legislators' perceptions about health and tobacco lobbyists, their frequency of contact with these lobbyists, and the amount of campaign contributions from health professional organisations and the tobacco industry. DESIGN: Cross-sectional study. SUBJECTS: State legislators from North Carolina, Texas, and Vermont (USA), serving in 1994. MAIN OUTCOME MEASURES: Perceptions about lobbyists representing the tobacco industry, non-profit health organisations, and state medical societies with respect to their credibility, importance as sources of information, and persuasiveness; extent of lobbying activities; campaign contributions from health professional organisations and the tobacco industry. RESULTS: Almost all legislators reported that medical society and non-profit health organisation lobbyists are credible on tobacco issues and just over half believed that these lobbyists are important sources of information. More legislators said they could be persuaded by medical and health lobbyists than by tobacco lobbyists. Although health professional Political Action Committees (PACs) gave campaign contributions to more state legislators, and gave higher amounts on average, than tobacco PACs, legislators reported less contact with medical society lobbyists than tobacco lobbyists about tobacco issues. CONCLUSIONS: State legislators have positive attitudes toward lobbyists for non-profit health organisations and state medical societies regarding tobacco issues. These groups may be an underused resource for educating legislators about tobacco control measures.
To describe the strategies pursued by the tobacco industry (TI) to interfere with the ratification of the WHO Framework Convention on Tobacco Control (FCTC) in Argentina.
We conducted semi-structured interviews about the FCTC, the TI and the legislative process with 3 legislators, 4 public health officials, 1 representative of the tobacco growers and two tobacco-control advocates. We reviewed 6 newspapers from the 4 tobacco growing provinces, searched TI documents in the Legacy Tobacco Documents Library and reviewed 1624 documents. Proposed legislation and related documents on tobacco control from Argentina’s National Congress and the Provincial Jujuy Congress were reviewed.
The principal strategy used by the TI was lobbying of provincial legislators and federal officials from the Ministry of the Economy by the tobacco growers associations. These legislators prevented the passage of comprehensive bills on tobacco control or of less comprehensive national laws. A typical legislative strategy used was to request additional analyses of the proposed bills from committees that prioritized economic issues over health. FCTC was mentioned in regional newspapers three to seven times per week in articles about alleged adverse economic effects of tobacco control. Direct physical threats to legislators who were openly supportive of FCTC ratification were made.
Tobacco producers and TI opposed FCTC ratification in Argentina by lobbying elected representatives and placing stories in regional media to obstruct approval of tobacco control laws. These activities have led to a delay in consideration of Argentina’s ratification of the FCTC despite the President’s signature in 2003. (250 words)
FCTC; Argentina; Tobacco Control
Background: Little is known about the differential impact of comprehensive and partial smoke-free legislation on smoking cessation. This study aimed to examine the impact of comprehensive smoke-free workplace legislation in Ireland and England, and partial hospitality industry legislation in the Netherlands on quit attempts and quit success. Methods: Nationally representative samples of 2,219 adult smokers were interviewed in three countries as part of the International Tobacco Control (ITC) Europe Surveys. Quit attempts and quit success were compared between period 1 (in which smoke-free legislation was implemented in Ireland and the Netherlands) and period 2 (in which smoke-free legislation was implemented in England). Results: In Ireland, significantly more smokers attempted to quit smoking in period 1 (50.5%) than in period 2 (36.4%) (p < 0.001). Percentages of quit attempts and quit success did not change significantly between periods in the Netherlands. English smokers were significantly more often successful in their quit attempt in period 2 (47.3%) than in period 1 (26.4%) (p = 0.011). In the first period there were more quit attempts in Ireland than in England and fewer in the Netherlands than in Ireland. Fewer smokers quitted successfully in the second period in both Ireland and the Netherlands than in England. Conclusion: The comprehensive smoke-free legislation in Ireland and England may have had positive effects on quit attempts and quit success respectively. The partial smoke-free legislation in the Netherlands probably had no effect on quit attempts or quit success. Therefore, it is recommended that countries implement comprehensive smoke-free legislation.
Objectives: To review the strategies employed by overseas cigarette manufacturers operating in Thailand to obstruct the passage and subsequent enforcement of national public health legislation, specifically the ingredients disclosure provision of the 1992 Tobacco Products Control Act.
Methods: Analysis of previously confidential tobacco industry documents relevant to non-compliance with the ingredients disclosure legislation.
Results: Requirement for disclosure of ingredients contained in cigarettes contained in the Tobacco Products Control Act was identified by transnational tobacco companies (TTCs) not only as a significant threat to their operations in Thailand, but as a dangerous global precedent. Industry documents reveal a determined campaign to block, stall, or amend the proposed regulation during the legislative process. Industry representatives petitioned the Ministry of Health to revise the requirement from by brand disclosure to a more palatable by company submission. Strategies were adapted in the wake of the passage of the Act. Most significantly, the industry in concert with embassies in Bangkok threatened the Thai government with appeals to international trade bodies on the grounds of violation of international agreements. Industry documents also reveal that as submission of ingredient lists appeared unavoidable, leading companies operating in Thailand endeavoured to confound the disclosure requirement by disguising ingredients and reformulating brand recipes.
Conclusions: The evidence presented highlights the importance of ingredients regulation and demonstrates how health policy can be transformed during its implementation. A greater understanding of trade agreements emerges as a priority for global tobacco control.