The Burden of Noncommunicable Diseases and the Current State of Noncommunicable Disease Prevention Regulation in the Caribbean

• Author: Tamu Davidson
• Pages: 1-28

The Burden of Noncommunicable Diseases and

the Current State of Noncommunicable Disease

Prevention Regulation in the Caribbean

Tamu Davidson1

Abstract

Noncommunicable diseases are the leading cause of premature death in the

Caribbean. Governments in the region have pledged to address noncommunicable

diseases in several global, regional and sub-regional mandates. However, the

implementation of legal measures to address these diseases and their risk factors

has been slow and inconsistent, exacerbated by the COVID-19 pandemic. Key

challenges include inconsistent political will, limited legal system capacity, and industry

interference. Nevertheless, growing political determination, increased domestic and

international support and the Caribbean Public Health Law Forum oer hope for

progress. This paper assesses the status of noncommunicable disease prevention

regulations in line with the World Health Organization’s ‘Best Buys’.

Keywords

Noncommunicable Diseases, Caribbean, Small Island Developing States,

Prevention Regulation, Public Health.

Introduction

The noncommunicable disease (NCD) epidemic, which has most recently been

referred to as a pandemic, is a major challenge to health and development, including

global health security.2 NCDs, or chronic diseases, are a group of conditions that “tend

1 Former Head Chronic Disease and Injury Prevention Department, Caribbean Public Health

Agency. Email: tamkdav@gmail.com

2 World Health Organization [WHO], ‘Non-communicable Diseases – Overview’ <https://www.

who.int/health-topics/noncommunicable-diseases#tab=tab_1> Accessed 12 December 2023; N

Unwin, F Mugusi, T Aspray, D Whiting, R Edwards, JC Mbanya, E Sobgnwi, S Rashid, KGMM

Alberti, ‘Tackling the emerging pandemic of non-communicable diseases in sub-Saharan Africa:

The essential NCD health intervention project’, Public Health, Volume 113, Issue 3, 1999, https://

doi.org/10.1038/sj.ph.1900549; Swarnakar R, Yadav SL. Communicable to Non-communicable

Disease Pandemic in the Making: An Urgent Call for Post-COVID-19 Preparedness. Cureus.

2022 Jul 29;14(7):e27453. doi: 10.7759/cureus.27453. PMID: 36051716; PMCID: PMC9420455.

2

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

to be of long duration, and are the result of a combination of genetic, physiological,

environmental and behavioural factors.”3 The main NCDs that cause most of the

death and disability globally include cardiovascular diseases (e.g., hypertension, heart

disease, heart attack, stroke), cancers, chronic respiratory diseases (e.g., asthma and

chronic obstructive airways diseases) and diabetes.4 These diseases share common

modiable risk factors, namely tobacco use, harmful use of alcohol, unhealthy diet

and physical inactivity.

5

These risk factors lead to metabolic changes including raised

blood glucose, raised blood pressure, overweight and obesity, and dyslipidaemia that

result in the development of NCDs.6 NCDs are mostly preventable by addressing

the risk factors, and legal interventions play a major role in this area of prevention.

7

According to Frieden, creating a supportive environment through the use of legal

interventions to make individuals’ default decisions the healthier, easier choice has

the greatest health impact.8

Caribbean governments have made several global, regional, and sub-regional

commitments to prevent and control NCDs. These include legally binding obligations,

such as the World Health Organisation (WHO) Framework Convention on Tobacco

Control (FCTC),9 to political instruments such as the 2007 Declaration of Port of

Spain “Uniting to stop the epidemic of chronic NCDs”,

10

the various interations of

the Caribbean Cooperation on Health, the United Nations (UN) 2030 Agenda for

Sustainable Development, including the Sustainable Development Goals (SDGs),

11

3 World Health Organization, ‘Non-communicable Diseases Key Facts’ (16 September 2022)

<https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases> Accessed

1 November 2023.

4 WHO, ‘Non-communicable Diseases Key Facts’ (16 September 2022) <https://www.who.int/

news-room/fact-sheets/detail/noncommunicable-diseases > Accessed 1 November 2023.

5 WHO, ‘Non-communicable Diseases Key Facts’ (16 September 2022) <https://www.who.int/

news-room/fact-sheets/detail/noncommunicable-diseases > Accessed 1 November 2023.

6 WHO, ‘Noncommunicable Diseases: NCD risk factors’ <https://www.emro.who.int/

noncommunicable-diseases/causes/index.html> Accessed 1 November 2023.

7 Roger S Magnusson, Benn McGrady, Lawrence Gostin, David Patterson, and Hala Abou Taleb,

‘Legal capacities required for prevention and control of noncommunicable diseases’ (2019) Bull

World Health Organ 1;97(2):108-117. doi: 10.2471/BLT.18.213777, Epub 2018 Nov 20. PMID:

30728617; PMCID: PMC6357565.

8 Thomas Frieden, ‘A Framework for Public Health Action: The Health Impact Pyramid’ (2010)

American journal of public health, 100. 590-5. 10.2105/AJPH.2009.185652.

9 WHO. WHO Framework Convention on Tobacco Control (2003) <https://fctc.who.int/

publications/i/item/9241591013> .

10Caribbean Community [CARICOM]. Declaration of Port-of-Spain: Uniting to Stop the Epidemic

of Chronic Noncommunicable Diseases. 15 September 2007.

11 United Nations [UN]. Transforming our world: the 2030 Agenda for Sustainable Development.

A/Res/70/1.

3The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

the 2011 and 2018 UN Political Declarations on NCDs,

12

as well as the more recent,

Bridgetown Declaration on NCDs and Mental Health,13 among others. These

commitments have cumulated in the global community, including the Caribbean

Community (CARICOM), agreeing to meet WHO’s nine (9) voluntary targets for

NCDs by 2025 and SDG target 3.4 as listed in Table 1.

Table 1: Global Targets for Noncommunicable Diseases

World Health Organisation’s Nine (9) Global Voluntary Targets for NCDs by 2025

Target 1: A 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes, or

chronic respiratory diseases.

Target 2: At least 10% relative reduction in the harmful use of alcohol as appropriate, within the

national context.

Target 3: A 10% relative reduction in prevalence of insufcient physical activity.

Target 4: A 30% relative reduction in mean population intake of salt/sodium.

Target 5: A 30% relative reduction in prevalence of current tobacco use in persons aged 15+ years.

Target 6: A 25% relative reduction in the prevalence of raised blood pressure or contain the prevalence of

raised blood pressure, according to national circumstances.

Target 7: Halt the rise in diabetes and obesity.

Target 8: At least 50% of eligible people receive drug therapy and counselling (including glycaemic control)

to prevent heart attacks and strokes.

Target 9: An 80% availability of the affordable basic technologies and essential medicines, including

generics, required to treat major noncommunicable diseases in both public and private facilities.

Sustainable Development Goals (SDGs) Targets

Target 3.4 Reduce by one third premature mortality from noncommunicable diseases through prevention

and treatment and promote mental health and well-being.

for%20030agenda>.

12UN. Political Declaration of the High-Level Meeting of the General Assembly on the Prevention

and Control of Non-Communicable Diseases : draft resolution / submitted by the President of

the General Assembly. UN. General Assembly (66th sess. : 2011-2012). [New York] : UN, 16

Sept. 2011; UN. Political declaration of the 3rd High-Level Meeting of the General Assembly

on the Prevention and Control of Non-Communicable Diseases : resolution / adopted by the

General Assembly. [New York] : UN, 17 Oct. 2018.

13<https://cdn.who.int/media/docs/default-source/ncds/sids-event/2023-bridgetown-declaration-

on-ncds-and-mental-health.pdf>

4

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Other NCD-related SDG Targets 14

Target 2.1: By 2030, end hunger and ensure access by all people, in particular the poor and people in

vulnerable situations, including infants, to safe, nutritious and sufcient food all year round.

Target 2.2: By 2030, end all forms of malnutrition; by 2025, achieve internationally agreed targets on

stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls,

pregnant and lactating women, and older persons.

Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drugs

and alcohol.

Target 3.8: Achieve universal health coverage, including nancial risk protection, access to essential

high-quality healthcare services, and access to safe, effective, high-quality, and affordable essential medi-

cines and vaccines for all people.

Target 3.9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals,

and reduce air, water, and soil pollution and contamination.

Target 3.a: Strengthen the implementation of the World Health Organization Framework Convention on

Tobacco Control in all countries, as appropriate.

Target 11.7: By 2030, provide universal access to safe, inclusive and accessible, green and public spaces,

in particular for women and children, older persons and persons with disabilities.

Targets for Goal 17 Strengthen the means of implementation and revitalize the global partnership for sus-

tainable development.

In order to achieve these targets, Appendix 3 of the Global Action Plan for the

Prevention and Control of Noncommunicable diseases 2013‒2020 (subsequently

extended to 2030)has a menu of policy options, including cost-eective solutions

for NCD prevention or ‘Best Buys’, which were developed to assist countries in

implementing actions within national contexts. In 2017, Appendix 3 was updated

to include 16 ‘Best Buys’ or cost-eective solutions for NCDs, of which at least 80%

require legal interventions.15 Subsequently, a draft 2022 update of Appendix 3 was

endorsed at the 76th World Health Assembly on the 30 May 2023, and there are

now 28 ‘Best Buys’ or policy options that are the most cost-eective and feasible for

implementation, of which 57% (16) require legal interventions for the prevention

of NCDs (See Table 3).16

14Project Everyone, ‘The 17 Goals’ <https://www.globalgoals.org/goals/> Accessed 1 November

2023; Lin Chen, Donghui Duan, Liyuan Han, Lu Xu, Sixuan Li, Yuwei Zhang, Wei Feng, Qinghai

Gong, Angela E. Micah, Ruijie Zhang, Shiwei Liu, Hui Li, ‘Non-communicable Disease-Related

Sustainable Development Goals for 66 Belt and Road Initiative Countries’ (2023) International

Journal of Health Policy and Management, 12, Issue 1, 1-13 doi: 10.34172/ijhpm.2022.6172.

15World Health Organization, ‘Tackling NCDs: ‘best buys’ and other recommended interventions

for the prevention and control of noncommunicable diseases’ (2017) <https://apps.who.int/iris/

handle/10665/259232> Accessed 21 July 2023.

16World Health Organisation, Seventy-Sixth World Health Assembly decision WHA76(9) ‘Political

5The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

This article reviews the current state of NCD prevention regulations in select

Small Island Developing States (SIDS) in the Caribbean with specic reference

to the WHO ‘Best Buys’ for the reduction of tobacco use, harmful use of alcohol

and unhealthy diet, and comments on the drivers of and barriers to eective NCD

regulation in these countries. All CARICOM Member states17 form the basis of

this review. The review was conducted drawing on NCD prevention laws that were

collected and analysed up to February 2023 using a standardized data capture

tool, online searches of legal, government and other databases. Prevalence data

on NCDs was obtained from a review of existing literature, online databases, such

as the WHO/Pan American Health Organization (PAHO) NCD data portal and

other published reports.

Noncommunicable Disease Burden

Over the past sixteen years, NCDs such as cardiovascular diseases, cancer,

diabetes, chronic respiratory diseases have been leading causes of mortality and

morbidity in the Caribbean (Figure 1).18 Caribbean countries have the highest

mortality rates due to the four major NCDs in the Americas and there is also a

gender dimension to the distribution of mortality, morbidity, disability and risk factors

for NCDs.19 The top three causes of disability-adjusted life years (DALYs) for both

sexes are diabetes mellitus (2491 DALY per 100,000 population), ischaemic heart

disease (1,881 DALY per 100,000 population) and stroke (1,704 DALY per 100,000

declaration of the third high-level meeting of the General Assembly on the prevention and control

of non-communicable diseases, and mental health’ (30 May 2023) <https://apps.who.int/gb/

ebwha/pdf_les/WHA76/A76(9)-en.pdf> Accessed 21 July 2023; World Health Organization,

Executive Board 152nd session Decision EB152/6 ‘Political declaration of the third high-level

meeting of the General Assembly on the prevention and control of non-communicable diseases

and mental health Draft updated menu of policy options and cost-eective interventions for

the prevention and control of noncommunicable diseases Report by the Director-General’ (10

January 2023) < https://apps.who.int/gb/ebwha/pdf_les/EB152/B152_6-en.pdf> Accessed

21 July 2023.

17The CARICOM Member States are: Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica

Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent

and the Grenadines, Suriname, and Trinidad and Tobago.

18 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes’ <https://www.paho.org/n/enlace> Accessed 30 January

2023>.

19 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes’ <https://www.paho.org/n/enlace> Accessed 30 January

2023.

6

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

population).20 However, for males the top three causes of DALY are interpersonal

violence, diabetes and ischaemic heart disease.21

20 Pan American Health Organization (PAHO) ENLACE: Data Portal on Noncommunicable

Diseases, Mental Health, and External Causes. Leading causes of death, and disability. Leading

causes of mortality and health loss at regional, subregional, and country levels in the Region of

the Americas, 2000-2019. ENLACE data portal. Pan American Health Organization; 2021.

21 Pan American Health Organization (PAHO) ENLACE: Data Portal on Noncommunicable

Diseases, Mental Health, and External Causes. Leading causes of death, and disability. Leading

causes of mortality and health loss at regional, subregional, and country levels in the Region of

the Americas, 2000-2019. ENLACE data portal. Pan American Health Organization; 2021.

rates per 100 000 population

Top 10 causes of Deaths

Non-Latin Caribbean, Both sexes, All Ages, 2019

1 Ischaemic heart disease

2 Stroke

3 Diabetes mellitus (excluding CKD due to Diabetes)

4 Interpersonal violence

5 Kidney diseases

6 Prostate cancer

7 Hypertensive heart disease

8 Lower respiratory infections

9 HIV/AIDS

10 Alzheimer disease and other dementias

010 20 30

16.8

22.8

22.9

24.2

25.5

30.6

36.6

70.4

83.5

90.7

40 50 6070 80 90

Communicable, maternal, perinatal and nutritional conditions

Noncocommunicable diseases

Injuries

Broad cause groups

rates per 100 000 population

Top 10 causes of Deaths

Non-Latin Caribbean, Male, All Ages, 2019

1 Ischaemic heart disease

2 Stroke

3 Diabetes mellitus (excluding CKD due to Diabetes)

4 Interpersonal violence

5 Prostate cancer

6 Kidney diseases

7 HIV/AIDS

8 Lower respiratory infections

9 Hypertensive heart disease

10 Road injury

010 20 30

22.5

23.7

24.5

30.9

34.8

51.5

61.5

64.5

81.6

101.9

40 50 6070 80 90 100110

Communicable, maternal, perinatal and nutritional conditions

Noncocommunicable diseases

Injuries

Broad cause groups

7The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Figure 1: Top 10 causes of death and disability in the Non-Latin Caribbean

by sex, 2019

Source: Pan American Health Organization (PAHO) ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes. Leading causes of death, and disability. Leading causes of mortality and

health loss at regional, subregional, and country levels in the Region of the Americas, 2000-2019. ENLACE data

portal. Pan American Health Organization; 2021

In 2019, a 30-year-old living in the Caribbean had the highest chance of dying

from any of the four major NCDs before reaching his or her 70th birthday (see

Table 2 and Figure 2). Between 2000 and 2019, there was a decline in premature

mortality in the non-Latin Caribbean by 18.5%.

rates per 100 000 population

Top 10 causes of Deaths

Non-Latin Caribbean, Both sexes, All Ages, 2019

1 Ischaemic heart disease

2 Stroke

3 Diabetes mellitus (excluding CKD due to Diabetes)

4 Interpersonal violence

5 Kidney diseases

6 Prostate cancer

7 Hypertensive heart disease

8 Lower respiratory infections

9 HIV/AIDS

10 Alzheimer disease and other dementias

010 20 30

16.8

22.8

22.9

24.2

25.5

30.6

36.6

70.4

83.5

90.7

40 50 6070 80 90

Communicable, maternal, perinatal and nutritional conditions

Noncocommunicable diseases

Injuries

Broad cause groups

rates per 100 000 population

Top 10 causes of Deaths

Non-Latin Caribbean, Male, All Ages, 2019

1 Ischaemic heart disease

2 Stroke

3 Diabetes mellitus (excluding CKD due to Diabetes)

4 Interpersonal violence

5 Prostate cancer

6 Kidney diseases

7 HIV/AIDS

8 Lower respiratory infections

9 Hypertensive heart disease

10 Road injury

010 20 30

22.5

23.7

24.5

30.9

34.8

51.5

61.5

64.5

81.6

101.9

40 50 6070 80 90 100110

Communicable, maternal, perinatal and nutritional conditions

Noncocommunicable diseases

Injuries

Broad cause groups

8

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Table 2: Top ve (5) countries with the highest probability of dying for the 4 NCDs by sex, 201922

Ranking Both sexesMale Female

1Haiti 31.4%Uruguay 11.1%Jamaica 9.1%

2Guyana 29.2%Grenada 9.5%Antigua & Barbuda 9.0%

3Grenada 23.3%Cuba 8.9%Grenada 8.7%

4Suriname 22.7%Saint Vincent &

Grenadines 8.9%

Barbados 8.3%

5Saint Vincent

& Grenadines 20.7%Argentina 8.3%Uruguay 7.7%

Figure 2: Trends in premature mortality from the four major NCDs by subregion 2000 & 2019

Source:PAHO ENLACE: Data Portal on Noncommunicable Diseases, Mental Health, and External Causes.

Monitoring the premature mortality from the four major noncommunicable diseases (cardiovascular diseases, cancer, diabetes mellitus,

and chronic respiratory diseases) in the Region of the Americas, 2000-2019. Pan American Health Organization. 2021.

Tobacco use

Globally and in the Americas, there has been a steady decline in tobacco use

across all age groups for both sexes in individuals 15 years and older.

23

The prevalence

of current tobacco use in Caribbean adults has also been declining from 2000 to

22 Pan American Health Organization, ‘Monitoring the premature mortality from the four major

noncommunicable diseases (cardiovascular diseases, cancer, diabetes mellitus, and chronic

respiratory diseases) in the Region of the Americas 2000-2019’ (PAHO 2021) <https://www.

paho.org/en/enlace/risk-dying-prematurely-ncds> Accessed 30 January 2023.

23World Health Organization, ‘World health statistics: monitoring health for the SDGs, Sustainable

Development Goals’ (WHO 2023); Pan American Health Organization, ‘ENLACE: Data Portal

on Noncommunicable Diseases, Mental Health, and External Causes Tobacco Use’ < https://

www.paho.org/en/enlace/tobacco-use > Accessed 30 January 2023.

2000 2019 2000 2019 2000 2019 20002019 2000 2019

2000 2019 2000 2019 2000 2019 2000 2019 2000 20192000 2019

30.0%

20.0%

10.0%

0.0%

20.0%

10.0%

0.0%

Non-Latin Caribbean Southern Cone Central America, Mexico and Andean Area North America

Latin Caribbean

Non-Latin Caribbean Southern Cone and Central America,Mexico Region of the Americas North America Andean Area

and Latin Caribbean

Brazil

Disparities across countries by subregion

Unconditional probability of dying from II.NCD4. Four major noncommunicable diseases (CVD, cancer, diabetes, and

Chronic respiratory diseases), 30-70 Both sexes, 2000 & 2019

23.2%

18.9% 20.8%

15.2% 17.1% 16.3% 18.2%

14.0%

17.7%

13.1%

15.1%

11.5%

Median

Median

Median

Median Median

Median

Median

Median

Median

Median

Cause

II.NCD4. Four major noncommunicable disease

Age group

30-70

Sex

Both sexes

Year

Multiple values

Year

2000

2019

9The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

2018 based on the available data, except for The Bahamas where the prevalence

has been increasing in men since 2015.24 The prevalence of current tobacco use

in adolescents (13-15 years old) in the Caribbean ranged from a high of 25.3%

(female 19.8% and male 30.4%) in Dominica to a low of 7.5% in Antigua and

Barbuda (female 7.0% and male 7.9%).25 The top three countries were Dominica,

Haiti and Jamaica.

Alcohol Use

At 10.37 litres, Barbados has the highest level of total alcohol per capita

consumption in both sexes combined in the Americas (1.8-fold higher than the

global level of 5.8 litres).26 The two other Caribbean countries in the top ve are

Saint Lucia (3rd at 9.59 litres) and Antigua and Barbuda (5th at 9.4 litres).27

Five of the top seven countries within the highest level of total alcohol drinker s

only per capita consumption for both sexes combined are in the Caribbean: Barbados

(4th), Grenada (5th), Dominica (6th), and Saint Vincent and the Grenadines (7th).28

Trinidad and Tobago has the highest level of heavy episodic drinking in the Americas

31.0%.29 Other Caribbean countries in the top seven are Saint Kitts and Nevis,

Barbados, Saint Lucia and Grenada.

24World Health Organization, ‘World health statistics: monitoring health for the SDGs, Sustainable

Development Goals’ (WHO 2023); Pan American Health Organization, ‘ENLACE: Data Portal

on Noncommunicable Diseases, Mental Health, and External Causes Tobacco Use’ <https://

www.paho.org/en/enlace/tobacco-use> Accessed 30 January 2023.

25World Health Organization, ‘World health statistics: monitoring health for the SDGs, Sustainable

Development Goals’ (WHO 2023); Pan American Health Organization, ‘ENLACE: Data Portal

on Noncommunicable Diseases, Mental Health, and External Causes Tobacco Use’ <https://

www.paho.org/en/enlace/tobacco-use> Accessed 30 January 2023.

26 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Alcohol consumption’ <https://www.paho.org/en/enlace/

alcohol-consumption> Accessed 30 January 2023.

27 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Alcohol consumption’ <https://www.paho.org/en/enlace/

alcohol-consumption> Accessed 30 January 2023.

28 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Alcohol consumption’ <https://www.paho.org/en/enlace/

alcohol-consumption> Accessed 30 January 2023.

29 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Alcohol consumption’ <https://www.paho.org/en/enlace/

alcohol-consumption> Accessed 30 January 2023.

10

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

The top ve countries in the Americas with the highest level of heavy episodic

drinking among adolescent drinkers are Trinidad and Tobago, Saint Kitts and Nevis,

Barbados, Saint Lucia and Grenada.30

Unhealthy Diet

The region of the Americas has the highest prevalence of obesity worldwide. In

2016, the estimated prevalence of overweight and obesity in the Caribbean ranged

from 73.2% in Bermuda, 69.9% in Bahamas to 56.2% in Trinidad and Tobago

for women, then, for men, 67.6% in Bermuda, 62.1% in Bahamas to 38.4% in

Trinidad and Tobago. 31 Further, across the Caribbean, the mean population salt

intake in adults ranged from 6.7 g/day in Barbados to 7.3 g/day in Trinidad and

Tobago, where the salt intake was 1.5-fold to the WHO recommendation of less

than 5 g/day.32

In 2019, the age-standardized prevalence of hypertension in the Caribbean of

both sexes combined varied across countries from a high of 47.7% in Dominica

to a low 38% in Belize. The countries with the highest prevalence are Dominica,

Grenada, Jamaica, followed by Saint Kitts and Nevis. All of these countries are in

the top 20% highest prevalence of hypertension for the Americas.33 There has also

been an increase in the standardized prevalence of diabetes between 2000 and 2014

in the Caribbean. The highest increases reported for men is 90.3% in Saint Lucia,

73.3% in Trinidad and Tobago, and 52.3% in Antigua and Barbuda whilst for

women is 65.9% in Saint Lucia, 60.5% in Trinidad and Tobago, and 54.4% in Haiti.

30 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Alcohol consumption’ <https://www.paho.org/en/enlace/

alcohol-consumption> Accessed 30 January 2023.

31 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Overweight and Obesity’ <https://www.paho.org/en/

enlace/overweight-and-obesity> Accessed 30 January 2023.

32 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Salt Intake’ <https://www.paho.org/en/enlace/salt-intake>

Accessed 30 January 2023.

33Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases, Mental

Health, and External Causes Hypertension’ <https://www.paho.org/en/enlace/hypertension>

Accessed 30 January 2023.

11 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Noncommunicable Disease Prevention Regulation

There are 28 Best Buys for NCDs in the WHO Appendix 3 2022 document for

NCDs, the majority of which require legal intervention (see Table 3). These are

the minimum interventions that countries should implement in order to achieve the

nine voluntary global WHO goals for 2025 and SDG 3.4.

Table 3: Menu of legally oriented WHO ‘Best Buys’ for NCD prevention

from the 2022 updates of Appendix 3 of the global NCD action plan

2013‒2030 endorsed at the 76th World Health Assembly May 202334

WHO Best BuysCriteria for meeting Target

TOBACCO USE

Increase excise taxes and prices on

tobacco products

Country has total taxes set at a level that

accounts for more than 75% of the retail price of

tobacco products

Implement large graphic health warnings on

all tobacco packages, accompanied by plain/

standardized packaging

Country has all public places completely smoke-

free (or at least 90% of the population covered by

complete subnational smoke-free legislation).

Enact and enforce comprehensive bans on tobacco

advertising, promotion and sponsorship

Country mandates plain/standardized packaging

and/or large graphic warnings with all appropriate

characteristics

Eliminate exposure to second-hand tobacco

smoke in all indoor workplaces, public places and

public transport

Country has a ban on all forms of direct and

indirect advertising

Provision of cost-covered effective population-wide

support (including brief advice, national toll-free quit

line services and Cessation) for tobacco cessation

to all tobacco users

Not available

ALCOHOL USE

Increase excise taxes on alcoholic beveragesCountry has excise tax on beer, wine, spirits; and

adjusts level of taxation for ination for alcoholic

beverages

34World Health Organization, Executive Board 152nd session Decision EB152/6 ‘Political declaration

of the third high-level meeting of the General Assembly on the prevention and control of

non-communicable diseases and mental health Draft updated menu of policy options and cost-

eective interventions for the prevention and control of noncommunicable diseases Report by

the Director-General’ (10 January 2023)

B152_6-en.pdf> Accessed 20 May 2023

12

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

WHO Best BuysCriteria for meeting Target

TOBACCO USE

Enact and enforce bans or comprehensive

restrictions on exposure to alcohol advertising

(across multiple types of media)

Country has regulatory or co-regulatory frameworks

for alcohol advertising through different channels

(public service/national TV, commercial/private TV,

national radio, local radio, print media, billboards,

points of sale, cinema, internet, social media); and

a detection system for infringements on marketing

restrictions

Enact and enforce restrictions on the physical

availability of retailed alcohol (via reduced

hours of sale)

Country has a licensing system or monopoly on

retail sales of beer, wine, spirits; restrictions for on-/

off-premises sales of beer, wine, spirits regarding

hours, days and locations of sales and legal age

limits for being sold and served alcoholic beverages

UNHEALTHY DIET

Reformulation policies for healthier food and

beverage products (for example, elimination of

trans-fatty acids and/or reduction of saturated fats,

free sugars and/or sodium)

Not available

Front-of-pack labelling as part of comprehensive

nutrition labelling policies for facilitating consumers’

understanding and choice of food for healthy diets

Not available

Public food procurement and service policies for

healthy diets (for example, to reduce the intake

of free sugars, sodium and unhealthy fats, and to

increase the consumption of legumes, wholegrains,

fruits and vegetables)

Not available

Policies to protect children from the harmful impact

of food marketing on diet

Not available

Protection, promotion and support of optimal

breastfeeding practices

Not available

However, Caribbean states have only made slow progress with respect to

implementation of these legal interventions for NCD prevention related to tobacco

use, harmful use of alcohol and unhealthy diet, and the situation has been exacerbated

by the COVID-19 pandemic. Fourteen (14) of the CARICOM Member States

(Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana,

Haiti, Jamaica, Saint Kitts and Nevis, Saint Lucia, St. Vincent and the Grenadines,

Suriname and Trinidad and Tobago) are parties to the WHO Framework Convention

13 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

on Tobacco Control Treaty (FCTC).35 Importantly, the WHO ‘Best Buys’ includes

interventions that align with select WHO FCTC articles.

There have been several approaches that Caribbean countries have taken to

implement the WHO Best Buy legal interventions related to tobacco. These include

through comprehensive Tobacco Control Acts (Suriname, Guyana and Antigua and

Barbuda),36 Tobacco Control Regulations (Jamaica, Saint Lucia, and Trinidad and

Tobago),37 the Health Services Act and accompanying regulations (Barbados)38 and

through other non-specic legislation or Executive Decisions (Belize).39

The use of price policies, specically taxation of tobacco products was the

most common legal intervention used even where there was no tobacco control

law (Grenada).40 Most countries (with the exception of The Bahamas) had a tax

on tobacco products ranging from 4% to 51.9% of excise tax of retail prices. The

approach to implementing these policies was mainly through an Excise Tax Act.

However, none of the selected countries has met the target of total taxes accounting

for more than 75% of the price of the most sold brand of cigarettes. Saint Lucia

was the only country to come close to meeting this target with total taxes accounting

for 63.5% of the price of the most sold brand of cigarettes.41 With the exception

of Grenada, there has been no recent increase in taxes over the last 2 years in the

selected countries.42

CARICOM Standard CRS 26:2012 requires that graphic health warnings be

located on at least 50% of the top or bottom half of both the front and back panels

of each package and placed on the front and back of packages. Seven Caribbean

35 United Nations, ‘UN Treaties Collections WHO Framework Convention on Tobacco

Control’<https://treaties.un.org/pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IX-

4&chapter=9&clang=_en> Accessed 30 January 2023.

36 Tobacco law, 2013 no 39 (Suriname); Tobacco Control Act 2017 (Guyana); Tobacco Control

Act 2018 (Antigua and Barbuda).

37Public Health (Tobacco Control) (Amendment) Regulations. 2014 (Jamaica); Tobacco Regulations

2013 (Trinidad and Tobago); Public Health (Smoking Control) Regulations 2020 (Saint Lucia).

38 Health Services Act amended 2009 (Barbados).

39 World Health Organisation, ‘Core questionnaire of the Reporting Instrument of WHO FCTC

(Belize 2020)’ <https://untobaccocontrol.org/impldb/wp-content/uploads/Belize_2020_

WHOFCTCreport.pdf> Accessed 01 February 2023.

40 Excise Tax Act 2010 (Grenada).

41 World Health Organization Framework Convention on Tobacco Control Secretariat, ‘Tobacco

Report Saint Lucia’ (WHO FCTC 2021) <https://untobaccocontrol.org/impldb/saint-lucia/>

Accessed 01 February 2023.

42 Linda Straker, ‘Increased VAT and Excise Tax go into effect’ NOW Grenada (Grenada 1 March

2023) <https://nowgrenada.com/2023/03/increased-vat-and-excise-tax-go-into-eect/> Accessed

29 June 2023.

14

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

countries (Antigua and Barbuda, Barbados, Guyana, Jamaica, St. Lucia, Suriname,

Trinidad and Tobago) have adopted this standard and met the target for this ‘Best

Buy’. This implementation has been done through Tobacco Control Acts, regulations

or national labelling standards (see Table 4). However, none of the selected countries

have implemented plain packaging. In other countries, such as, Bahamas, Grenada,

Haiti, Montserrat, and Saint Vincent and the Grenadines, there are no laws requiring

health warnings, and Belize requires text health warnings.43 Haiti signed the WHO

FCTC but has not ratied it.

Table 4: Caribbean countries that have adopted graphic health warnings

on tobacco products in keeping with CARICOM Standard CRS 26:2012

and WHO Best Buy for tobacco.44

Country Law/National Labelling StandardRequirements

Antigua

and Barbuda

Tobacco Control Act 2018Rotating pictorial health warnings that

cover 50% of the front and back of

tobacco product packaging.

Misleading packaging and labelling,

including terms such as “light” and “low

tar” and other signs are prohibited.

BarbadosHealth Services (Packaging and

Labelling of Tobacco Products)

Regulations, 2017

Health warnings are pictorial as well as

text and must cover 60% of the front

and back of packages and be rotated

every 12 months.

GuyanaTobacco Control Act 2017 and

Tobacco Products’ Packaging and

Labelling Regulations 2018

Rotating combined picture and text health

warnings are required to be displayed

on 60 % of the front and back of tobacco

product packages.

JamaicaPublic Health (Tobacco Control)

Regulations, 2013 and Public Health

(Tobacco Control) (Amendment)

Regulations, 2014.

Rotating graphic health warnings are

required on 60% of the two principal

display areas (front and back) on both unit

and outside packaging.

Saint LuciaSaint Lucia National Standard

27:2016, Specication for Labelling of

Tobacco Products

Rotating graphic health warnings are

required on 50 % of the two principal

display areas (front and back) on both unit

and outside packaging.

43 Belize National Standard on Labelling of Retail Packages of Cigarettes (First Revision), BZS 1:

Part 4: 2006.

44Campaign for Tobacco-Free Kids, ‘Country data’ < https://www.tobaccocontrollaws.org> Accessed

01 February 2023; WHO FCTC Convention Secretariat, ‘World Health Organisation Framework

Convention on Tobacco Control Implementation Database’ < http://untobaccocontrol.org/

impldb/parties/> Accessed 01 February 2023.

15 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Country Law/National Labelling StandardRequirements

SurinameState Gazette 2013 No. 39

Law of 20th February 2013,

Containing Rules for Limiting the Use

of Tobacco and Tobacco Products

(Tobacco Law); Decision of the

Minister of Public Health of December

9, 2013 No. 4061/13; Decree of

the Minister of Public Health of 03

May, 2018 no. 1391, determining

the adoption of a new set of health

warnings pursuant to Article 5(b) of

the Decree of the Minister of Public

Health of 09 December 2013 no.

4061/13 (S.B. 2013 no. 207).

Combined picture and text warnings must

cover at least 50% of the front and back

of the packaging, on the upper portion of

the package.

For conical packages, warnings must

cover at least 50% of the surface area, in

a rectangular format.

Warnings must also be printed on any

inserts or onserts.

Trinidad and TobagoTobacco Control Regulations, 2013Rotating text and picture health

warning covering at least 50 % of the

front and back surfaces of tobacco

product packaging.

There are comprehensive bans on tobacco advertising, promotion and sponsorship

(TAPS) under the law (Tobacco Control Acts) in Guyana,

45

Suriname

46

and Antigua

and Barbuda.

47

These countries have met the target as there is a ban on all forms of

indirect and direct advertisement of tobacco products. There are no specic laws

that fully ban TAPS in other Caribbean countries. For example, in Jamaica, there

are several laws that address the means of tobacco advertisement.

Only seven Caribbean countries are 100% smoke-free, that is, they have laws

that eliminate exposure to second-hand tobacco smoke in all indoor workplaces,

public places, public transport.48

45 Tobacco Control Act 2019 Part VI, s19 (Guyana).

46Act of February 20, 2013 Laying Down Rules Limiting the Use of Tobacco and Tobacco Products

(Tobacco Act) Article 5.

47 Tobacco Control Act 2018 s16 from Antigua and Barbuda.

48 WHO FCTC Convention Secretariat, ‘World Health Organisation Framework Convention on

Tobacco Control Implementation Database’ <http://untobaccocontrol.org/impldb/parties/>

Accessed 01 February 2023.

16

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

CARICOM has draft standards for Tobacco Products Advertising, Promotion,

Sale and Sponsorship Specication DCRS 60: 202Xcurrently under consideration.

In 2020, Jamaica tabled a comprehensive Tobacco Bill 2020 in Parliament that

will implement all of WHO ‘Best Buys’ among other WHO FCTC measures.49

The Bill is being currently being deliberated by a Joint Select Committee and has

gone through a series of stakeholder consultations. Both Saint Lucia and Belize are

advancing work on their respective draft Tobacco Control Bills and The Bahamas

in 2019 had developed draft national standards for TAPS.

Implementation of the WHO ‘Best Buys’ legal interventions for alcohol has been

undertaken using several laws such as, Road Trac Acts, Spirit or Liquor Licensing

Acts and Excise Tax Acts, rather one comprehensive piece of legislation. Some

Caribbean countries have also used legal interventions for price policies, such as taxes

on alcoholic beverages as well as age restrictions, blood alcohol concentration limits

for drivers, penalties for drink-driving and restrictions on the physical availability

of retailed alcohol (via reduced hours of sale).50 None of the selected countries

has evidence of fully implemented laws with bans or comprehensive restrictions

on exposure to alcohol advertising, promotion and sponsorship across multiple

types of media.

Four countries (Jamaica, Saint Kitts and Nevis, Suriname, Grenada) have fully

implemented the legal intervention in respect of price policies for alcohol, as in

addition to the excise tax, there are no tax incentives or rebates for production of

other alcoholic beverages and adjustments of the level of taxation for ination for

beer, wine, and spirits have been implemented.51 In 2023, Antigua and Barbuda

49 Tobacco Control Bill 2020 (Jamaica).

50 Examples are: Road Trac Act 2018 and the Road Trac Regulations 2022 from Jamaica;

Liquor Licenses Act 2002 from Saint Kitts and Nevis; Excise Tax Act 2005 from Saint Lucia.

51Act of Tari of Import duties (1996, S.B. 1995 no. 111) and other applicable laws regarding the

levying of excise duties on alcoholic and non-alcoholic beverages, tobacco and tobacco products,

and the consumption tax on motor fuels (Suriname); Excise Duty Act 1942 (Jamaica); Excise Tax

Act 2010 (Saint Kitts and Nevis); Excise Tax Act 2010 and Statutory Rules and Orders No. 3 OF

2023, Excise Tax Order 2023 (Grenada); Fabian B. Lewis and Sharmaine Edwards, ‘Evolution

of Jamaica’s Excise Tax Regime for Alcohol and Tobacco Products’ and Marita Wijnerman

and Johanna Lakhisaran ‘Alcohol Taxation Suriname” (PAHO/WHO Caribbean Subregional

Workshop on Alcohol, Tobacco and Sugar-Sweetened Beverages Taxation, Barbados, 17 May

2017);World Health Organization, ‘Tax incentives for production of other alcoholic beverages by

country ‘ (WHO 2018) <https://apps.who.int/gho/data/node.main.A1188_D?lang=fr> accessed

05 May 2023; ‘Increased VAT and Excise Tax go into eect’ NOWGrenada (1 March 2023)

<https://nowgrenada.com/2023/03/increased-vat-and-excise-tax-go-into-eect/> Accessed 20

June 2023. See also, Maxime Roche, Rosa Carolina Sandoval, Maristela G. Monteiro, ‘Comparing

taxes on alcoholic beverages in the Region of the Americas’ (Addiction 2023; 118(7): 1389–1395)

17 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

announced that it will introduce a 10% excise tax on alcohol, shifting from its former

position of zero taxes.

52

The remaining selected countries have all partially met the

target as they have excise taxes on alcohol.

As it relates to unhealthy diets, to date no legal interventions have been

implemented in the selected countries to address the WHO ‘Best Buys’ to reduce

sodium/salt intake. Barbados, however, has a policy for reformulating food products

with voluntary sodium/salt reduction target levels for the amount of salt in foods

and meals.53 Additionally, Barbados has dietary and nutrition guidelines for the

establishment of a supportive environment in public institutions, specically the

school setting, to enable lower sodium options to be provided.54 Further, in April

2023, Barbados started to implement its National School Nutrition Policy, which

directly addresses the school food environment.55

Across the selected countries no legal interventions have been implemented

to eliminate or ban the use of industrial trans-fats in the food chain. However, at

the Joint Sixth Joint Council for Trade and Economic Development (COTED)

and Council for Human and Social Development (COHSOD), Ministers agreed

to work towards the elimination of partially hydrogenated oils (PHOs) from the

regional food supply by December 2024.56 There have been pronouncements from

some countries, such as, Jamaica, where the Minister of Health and Wellness, Dr.

The Honourable Christopher Tufton, in his contribution to the 2022/23 Sectoral

<https://doi.org/10.1111/add.16146> Accessed 30 June 2023.

52 Excise Tax Act 1903 (Antigua and Barbuda); Intoxicating Liquor (Price Control) Act, Cap.

224, section 4A. https://laws.gov.ag/wp-content/uploads/2023/12/Revenue-Miscellaneous-

Provisions-Bill-2023-FINAL.pdf.

53 Pan American Health Organization, ‘Mapping Dietary Salt/Sodium Reduction Policies and

Initiatives in the Region of the Americas’ (PAHO 2021) < https://www.paho.org/en/documents/

mapping-dietary-saltsodium-reduction-policies-and-initiatives-region-americas> Accessed 01

February 2023.

54 ibid.

55Government of Barbados. ‘Barbados School Nutrition Policy – Snacks and Drinks’ <https://mes.

gov.bb/News/Latest/Barbados-School-Nutrition-Policy-Snacks-Drinks.aspx> Accessed January

23, 2024.

56A copy of the actual decision emanating from the Sixth Joint Meeting of COTED and COHSOD

in 2022 was not publicly available at the time of writing this article.

18

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Debate in the House of Representatives, informed that Jamaica has started working

towards the elimination of industrial trans fats in the food system.57 More recently,

Barbados’ Minister of Health and Wellness, Senator Dr. The Most Honourable

Jerome Walcott, at the Small Island Developing States (SIDS) High-Level Technical

Meeting on NCDs informed of Barbados’ commitment to have policies in place to

remove industrial trans-fats for their food supply by December 2024.58

With respect to front-of-package nutritional labelling, there has been an ongoing

regional process under the auspices of the CARICOM Regional Organization for

Standards and Quality (CROSQ) which is seeking to arrive at a regional FOPL

standard that can then be implemented across CARICOM Member States.59 The

proposed draft model standard uses the high-in black octagonal warning labels which

has been found to be the most eective model.60 However, the regional standard was

rejected in the most recent round of voting in 2023, where seven countries opposed,

ve countries supported and three countries abstained.61

Eight Caribbean countries (see Table 5) have introduced taxes on sugar-

sweetened beverages to reduce sugar consumption.

57 Christ Patterson, ‘Health Ministry Takes Action To Remove Trans Fats From Local Foods’

(Jamaica Information Service, 8 May 2022) < https://jis.gov.jm/health-ministry-takes-action-

to-remove-trans-fats-from-local-foods/ > Accessed 39 June 2023.

58 Melissa Rollock, ‘Plans To Clamp Down On Trans Fats In Local Foods’ (Barbados Information

Service, 17 January 2023) <https://gisbarbados.gov.bb/blog/plans-to-clamp-down-on-trans-

fats-in-local-foods/> Accessed 30 Jun 2023.

59 Draft Caricom Regional Standard Labelling of Foods Pre-Packaged Foods Specication (Revision)

DCRS 5: 202X.

60 PAHO/WHO, ‘Superior Ecacy of Front-of-Package Warning Labels in Jamaica’ (March

2021) <https://iris.paho.org/bitstream/handle/10665.2/53328/PAHONMHRF210002_eng.

pdf ?sequence=1&isAllowed=y> Accessed 1 April 2024; White-Barrow V, Gomes FS, Eyre S, et al,

‘Eects of front-of-package nutrition labelling systems on understanding and purchase intention

in Jamaica: results from a multiarm randomised controlled trial’ (2023) BMJ Open 13:e065620

<https://bmjopen.bmj.com/content/13/4/e065620> Accessed 1 April 2024.

61Lake, S., Barbosa, I., Benjamin, K., Constantin, A., Hutton, M., and Foster N. Public Health

Decision-Making in CARICOM: Strengthening the Front-of-Package Nutrition Labelling

Standardisation Programme (March 2024). Report of the Global Center for Legal Innovation

on Food Environments, the Healthy Caribbean Coalition and the Law and Health Research

Unit of the Faculty of Law, University of the West Indies, Cave Hill.

19 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Table 5: Caribbean counties that have applied excise taxes on sugar

sweetened beverages (SSBs) based on legislation in eect as of 31

March 202362,63

Caribbean

countries

Tax StructureLegislation Product(s) taxed

Barbados • Ad valorem

• Tax base for locally

produced beverages

producer price.

• Uniform tax rate

Excise Tax (Amendment)

(NO.3) Regulations 2017

10% excise tax

POLICY NOTE P&F No.

004/2022

Policy & Forecasting

Budgetary Proposals and

Financial Statement 2022:

Effective April 1, 2022, the

rate of excise tax imposed on

sweetened beverages is 20%

Applies on powders,

concentrates, or syrups,

energy drinks, and

sugar-sweetened milk

drinks

Exempts 100% juice,

coconut water, and plain

milk

Belize • Amount -specic

• Uniform tax

Customs and Excise Duties

(Amendment) Act N 29, 2017

Applies on bottled water,

and energy drinks

Dominica • Combined (At least

one type of non-

alcoholic beverage

is taxed by an ad

valorem excise tax and

at least one other type

is taxed by an amount-

specic excise tax. No

beverage type is taxed

by both)

• Tax base for locally

produced beverages

producer price

• Tax rate tiered

Excise Tax (Amendment), SRO

N 28 of 2015; Excise Tax Act

8, 2005

10% excise tax

Applies on powders,

concentrates, or syrups,

and on energy drinks

62Rosa Carolina Sandoval, Maxime Roche, Itziar Belausteguigoitia, Miriam Alvarado, Luis Galicia,

Fabio S. Gomes, and Guillermo Paraje, ‘Excise taxes on sugar-sweetened bever ages in Latin

America and the Caribbean’ (Rev Panam Salud Publica. 2021;45:e2) < https://doi.org/10.26633/

RPSP.2021.2 > Accessed 20 February 2023.

63 Global Health Advocator Incubator, Global Food Research Program, University of North

Carolina at Chapel Hill, ‘Sugar-Sweetened Beverage Taxation – Industry Arguments Counter

Messages and Evidence’ (Updated August 2, 2022).

20

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Caribbean

countries

Tax StructureLegislation Product(s) taxed

Grenada64 • Value Added TaxValue Added Tax (VAT) Act

23 2009; Value Added Tax

(Amendment) (No. 2) Regu-

lations 2023 (Grenada) 5th

Schedule, implemented 1

March 2023

Applies on beverages

containing added sugar

or other sweetening

matter (20% VAT), and

naturally sweetened and

other beverages (15%

VAT). Does not include

fruit juices (including

grape must) and vege-

table juices containing

added spirit whether or

not containing added

sugar or other sweet-

ened matter. Exempts

milk and soya based

preparations for infant

use, put up for retail sale

Saint Kitts and

Nevis

• Ad valorem

• Tax base for locally

produced beverages

• retail price excluding

VAT

• Uniform tax rate

Excise Tax Act No. 4, 2010Applies on energy drinks

Saint Vincent

and the Grena-

dines

• Ad valorem

• Tax base for locally

produced beverages

• retail price excluding

VAT

• Uniform tax rate

Excise Tax Act Chapter 430

SRO 2

Applies on energy

drinks, and sugar-sweet-

ened milk drinks

Suriname • Amount -specic

• Uniform tax rate

S.B. 2006 no. 27 wijz. Wet

Accijns Alcoholvrije Dranken

Applies on bottled water,

powders, concentrates

or syrups, and energy

drinks

64 Statutory Rules Order No. 12 Value Added Tax (Amendment) (No. 2) Regulations 2023

(Grenada),s4B, 5th Schedule.

21 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Caribbean

countries

Tax StructureLegislation Product(s) taxed

Bermuda • Import tax• Customs Tariff Amendment

(No 2) Act 2018

• Increased from 33.5%

to 50% import tax on

sugary soft drinks,

candies, and raw

sugar

• In 2019, increased

tax to 75% import

tax and extended to

select products with

cocoa (e.g., chocolate

confectionary).

• Exempts diet sodas,

100% juice, and diet

iced tea.

• Tax on fruit and

vegetables such as

cauliower, broccoli,

turnips, potatoes,

oranges, and apples,

previously at 5%, was

removed

Drivers and Barriers to the Region’s NCD Prevention Eorts

The selected territories have not implemented most of the legal interventions

recommended for NCD prevention. Most progress has been made with respect to

tobacco and alcohol, with the most popular interventions being price policies but even

then, the price policies are not high enough to have the fully desired health impact.

65

Some of the arguments have been that barriers to advancing the legal response

to NCDs in the Caribbean include the lack of political will, inadequate capacity

of the legal system, high corporate permeation and the eects of the commercial

determinants of health, that is “the private sector activities that aect people’s health,

65 Rosa Carolina Sandoval, Sehr Malik, Maxime Roche, Itziar Belausteguigoitia and Gilberto

Morales-Zamora, ‘Lessons learned from fostering tobacco taxes in the Americas and implications

for other health taxes’ (Rev Panam Salud Publica. 2022;46:e188)< https://doi.org/10.26633/

RPSP.2022.188> Accessed 1 April 2023; Maxime Roche, Rosa Carolina Sandoval, Maristela G.

Monteiro, ‘Comparing taxes on alcoholic beverages in the Region of the Americas’ (Addiction

2023; 118(7): 1389–1395) < https://doi.org/10.1111/add.16146> accessed 1 April 2023.

22

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

directly or indirectly, positively or negatively”.

66

The Caribbean’s law-making process

is generally characterised as very slow, where a Bill may take over 10 years or more

to be passed. There is also little or an absence of policy surveillance, monitoring and

evaluation once laws are implemented to assess their impact. However, this may be

changing with the increased international support.

Political will

Political will is essential to the passing of legislation for NCD prevention. The

political directorate plays a central role in the development and passage of legislation.

In the case of Antigua and Barbuda’s Tobacco Control Act, several Parliamentarians

‘raised a rights-framed challenge’ against the provisions of the legislation when it was

proposed.67 ‘Proximity between political actors or sympathies of legislators who are

smokers’ was also identied as a major barrier to legislative process.68 There have

also been arguments for more relevant national evidence to justify regulating NCDs.

Additionally, even when there is political will this may be thwarted by a change in

administration from one election cycle to another having to make the case for the

legislative agenda.

Capacity of the legal system

Traditionally, the Caribbean has been noted for its slow development and

enactment of laws, there is also inadequate legal expertise in public health and

medical law in the Region, more so in the context of NCDs. In the case of Antigua and

Barbuda, a lack of experience with developing tobacco control legislation was a barrier

in developing their tobacco legislation and inadequate technical support delayed

implementation in 2022.69 There is also limited capacity in the Caribbean, once

laws are passed for surveillance, monitoring and evaluation of their implementation.

Except for the monitoring by WHO, PAHO, CARICOM and other international

66 WHO. ‘Commercial determinants of health’ (21 March 2023). < https://www.who.int/news-

room/fact-sheets/detail/commercial-determinants-of-health>.

67‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf > Accessed 1 July 2023.

68 ibid 27.

69‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf > Accessed 1 July 2023.

23 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

agencies on the progress in enacting the required laws, there is little information on

the eectiveness and level of implementation.

High corporate permeation and eects of the commercial

determinants of health

Industry interference has been identied as a signicant barrier to NCD prevention

regulation in the Caribbean, aecting all stages of the legislative process, from

drafting to implementation. In the cases of Antigua and Barbuda, Jamaica and Saint

Lucia, industry interference occurred from the drafting to implementation stage of

their respective tobacco control laws.70 Industry arguments often frame concerns

around human rights, trade and economic consequences and advocate for more

voluntary measures. Eorts to advance the legal measures to improve the food and

obesogenic environment have been impacted and progress slow with the food and

beverage industry using tactics, such as the ‘exploitation of regional integration

mechanisms and co-opted human rights and decolonization narratives to advance

their cause’.71 The “food and beverage industry worked assiduously to undermine

CROSQ’s front-of-package nutritional labelling” development process.72

Some of the facilitators include technical support provided by health agencies,

wide multisectoral collaboration, high political will and commitment supported by

a strong civil society.

70‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf > Accessed 1 July 2023; Nicole

Foster, Implementation of the WHO Framework Convention on Tobacco Control in Saint Lucia

- A Case Study Implementation of The WHO Framework Convention on Tobacco Control In

Saint Lucia (23 May 2022) <https://www.healthycaribbean.org/wp-content/uploads/2022/05/

Implementation-of-the-WHO-Framework-Convention-on-Tobacco-Control-in-Saint-Lucia-Case-

Study-May-2022.pdf> Accessed 1 July 2023; Healthy Caribbean Coalition, ‘Civil Society Led

Tobacco Control Advocacy in the Caribbean Experiences from The Jamaica Coalition for

Tobacco Control’ (Healthy Caribbean Coalition December 2016).

71 Nicole Foster, Andres Constantin, Shajoe Lake, ‘CARICOM’s Eorts to Tackle Unhealthy Diets:

A Cautionary Tale for Latin America’ (Rei-Revista Estudos Institucionais, 8. 254-279,10.21783/

Rei.V8i2.663 2022).

72 Ibid. See also, Lake, S., Barbosa, I., Benjamin, K., Constantin, A., Hutton, M., and Foster, N.

Public Health Decision-Making in CARICOM: Strengthening the Front-of-Package Nutrition

Labelling Standardisation Programme (January 2024). Report of the Global Center for Legal

Innovation on Food Environments, the Healthy Caribbean Coalition and the Law and Health

Research Unit of the Faculty of Law, University of the West Indies, Cave Hill.

24

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

Technical support by health agencies

Public health agencies, such as the Caribbean Public Health Agency, the Pan

American Health Organization and World Health Organization play a critical role

in providing technical cooperation and developing regional policies. Funding and

technical support along with advocacy from PAHO, along with sharing of experience

from other countries has been reported as important factors in advancing tobacco

control laws, for example in Antigua and Barbuda, and regulation of unhealthy diets.

73

Whole of Government coordination

The majority of the interventions for NCD prevention lie outside of the health

sector with a heavy reliance on other Ministries Departments and Agencies. Hence, a

whole-of-government approach is required to eectively implement the WHO ‘Best

Buys’ legal interventions.74 Whole-of-government requires collaboration between

dierent Ministries and Departments, such as, health, nance, transportation,

education, agriculture, trade, including their Agencies with a view to taking a

health-in-all policies approach and having a combined response. In the Caribbean

context, a whole-of-government approach is built into the processes for legislation

development. Despite this, there are consistently competing priorities amongst

Government Agencies and challenges nding common language and win-win

situations. Perhaps, an Inter-Ministerial Commission or Committee or Council,

or alternatively, a Joint Committee on NCD prevention addressing the priority

risk factors appointed by the Prime Minister would be the approach to take in the

Caribbean context. The Ministers of COTED and COHSOD have been jointly

working to address diet-related NCDs and harmful use of alcohol.75 A strong

cross-sectoral response was a major driving factor for advancing tobacco control

law in Antigua and Barbuda that strengthened coordination, mitigated against

external inuences, advocated for and supported implementation of the legislation.

76

73‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf > Accessed 1 July 2023.

74 United Nations General Assembly (UNGA) Resolution, A/RES/66/2 ‘Political Declaration

of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-

Communicable Diseases’ (16 September 2011)

75 Douglas Slater, Laurette Bristol, Karen Gordon Boyle, ‘Healthy lives, education and wealth:

ecological relationships in social resilience’ (Rev Panam Salud Publica. 2022 Aug 25;46:e57)

< 10.26633/RPSP.2022.57> Accessed 30 July 2023.

76‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

25 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

In most Caribbean countries, the Ministries of Health are working jointly with the

Ministries of Education to support the development and implementation of school

nutrition policies, such as the administrative prohibition and restriction of the sale

or serving of sugar-sweetened beverages in public schools in Trinidad and Tobago.

In Jamaica, this collaboration also extends to the Ministry of Agriculture in relation

to the National Food and Nutrition Security Policy.

In the context of the whole-of-society response, civil society plays a central role

in advocacy and raising awareness around NCD prevention public health measures,

along with community-based and faith-based organisations in the Caribbean context.

Public awareness and support are important to aid in advancing eorts to regulate

NCD policies. It is also necessary to address training and capacity building, identify

and close the research gaps and support policy surveillance which can be addressed

by academia and professional organizations.

Political will

High political will has played a pivotal role in the advancement of legislation

regulating NCD prevention in Caribbean countries. Notably, there has been strong

regional political will, as demonstrated by the 2007 Port of Spain declaration and the

subsequent 2008 St. Ann’s Declaration, both aimed at addressing chronic NCDs in

the Caribbean. Former Prime Minister of Grenada and Chair of the 38th Meeting

of the Conference of Heads of Government, The Honourable Keith Mitchell

emphasized the region’s commitment to addressing NCDs through legislation and

public education eorts:

“We have issued a statement reiterating our determination to curb the ravages

of these diseases through legislation and intensied public education activities. We

simply cannot aord to continue the lifestyle and food consumption patterns that

are literally killing us”.77

In specic instances, such as in Saint Lucia and Antigua and Barbuda, robust

political support was evident within a whole-of-government approach towards

managing the NCD response. This approach resulted in the enactment of their

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf > Accessed 1 July 2023.

77 Food4 Change Caribbean, CARICOM leaders: Breakthrough in the ght against NCDs in the

region

ncds-in-the-region/ > Accessed 1 July 2023.

26

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

respective Tobacco Laws, showcasing the importance of political will in advancing

NCD prevention measures.78

Strong civil society support

There is strong support and mobilisation of national and regional civil society

through organisations such as Healthy Caribbean Coalition. Civil society support

has played an important role in advancing tobacco control laws, regulation of

unhealthy diet, advocacy for alcohol policies along with mitigating against industry

interference. It is increasingly recognised that:

“The factors for success of advocacy for tobacco control at a CSO level is

driven in part by CSO members who have prominence, charisma, and strong

community relations that enable them to act as strong champions for advancing

tobacco control measures.”79

Lessons Learnt from the COVID-19 Pandemic

The COVID-19 pandemic has also demonstrated that in the context of strong

political leadership and support, the Caribbean law-making machinery can be nimble

and respond to public health threats. Additionally, the need for multidisciplinary,

multisectoral, inclusive, whole-of-government, whole-of-society approach to addressing

a pandemic is doable in the Caribbean context. Perhaps it is long overdue for NCDs

to be declared a pandemic. This may provide the needed catalyst to accelerate

implementation.

Declaring a disease to be a public health emergency and further, a pandemic,

activates a range of public health powers. These powers enable the coordination and

mobilization of eorts across government departments and agencies, sectors, and

society as a whole. They facilitate resource allocation, address disease risk factors, excess

78‘Rashad Brathwaite, ‘Implementation of the WHO Framework Convention on Tobacco Control

in Antigua & Barbuda: A Case Study’; (May 2022) <https://www.healthycaribbean.org/wp-

content/uploads/2022/05/Implementation-of-the-WHO-Framework-Convention-on-Tobacco-

Control-in-Antigua-and-Barbuda-Case-Study-May-2022.pdf> Accessed 1 July 2023; Nicole

Foster, Implementation of the WHO Framework Convention on Tobacco Control in Saint Lucia

- A Case Study Implementation of The Who Framework Convention on Tobacco Control In

Saint Lucia (23 May 2022) <https://www.healthycaribbean.org/wp-content/uploads/2022/05/

Implementation-of-the-WHO-Framework-Convention-on-Tobacco-Control-in-Saint-Lucia-Case-

Study-May-2022.pdf> Accessed 1 July 2023.

79 Healthy Caribbean Coalition, ‘Civil Society Led Tobacco Control Advocacy in the Caribbean

Experiences from The Jamaica Coalition for Tobacco Control’ (Healthy Caribbean Coalition

December 2016).

27 The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

morbidity and mortality, and potentially redene the scope of healthcare practices.

Importantly, such declarations allow for a more adaptable and exible approach to

creating laws and regulations. However, it is essential to strike a balance between

individual rights, the eectiveness of these measures, and political accountability

while exercising these powers.80

Conclusion

The Caribbean faces a signicant burden of NCDs, where individuals are dying

in the prime of their lives due to these diseases. This loss of human capital impacts

not just health but also the development of the region and the ability to address

other public health emergencies and societal problems. Despite slow progress, the

region has made eorts to regulate NCD prevention aligned to the WHO ‘Best Buys’.

CARICOM leadership and commitment remain high and was recently reenforced

in the SIDS 2023 Bridgetown Declaration on NCDs and Mental Health.81 Taxation

has been a popular legal tool, with several countries implementing tobacco and

alcohol taxes as well as adopting sugar taxes. Development and implementation of

tobacco control laws, especially smoke-free laws as well as alcohol control laws have

also seen progress, while regulating unhealthy diets lags behind. An encouraging

trend and projection for Jamaica and Guyana show that they are on the trajectory

to meeting the 2025 global targets for addressing the risk factor of tobacco use, with

their respective legislation to regulate such.82 However, other eorts to regulate NCD

prevention have been mainly stymied due to inconsistent political will, limited legal

system capacity and the commercial determinants of health.

However, “[t]he eective use of law and regulation lies at the heart of successful

preventing noncommunicable disease”. Hence, the legal profession’s involvement is

critical in making this a reality.83 The legal landscape is changing in the Caribbean

with national and international technical support and funding. The establishment

80 Montrece McNeill Ransom, Laura Magana Valladeres, Public Health Law Concepts and Case

Studies (1st Springer Publishing edition 2022).

81WHO/PAHO, SIDS Health, NCDs and Mental Health. 2023 Bridgetown Declaration on NCDs

and Mental Health. <https://cdn.who.int/media/docs/default-source/ncds/sids-event/2023-

bridgetown-declaration-on-ncds-and-mental-health.pdf?sfvrsn=5feda33f_11>.

82 Pan American Health Organization, ‘ENLACE: Data Portal on Noncommunicable Diseases,

Mental Health, and External Causes Tobacco Use’ <https://www.paho.org/en/enlace/tobacco-

use> Accessed 30 January 2023.

83 Roger Magnusson, Benn McGrady, Lawrence Gostin, David Patterson, and Hala Abou Taleb,

‘Legal capacities required for prevention and control of noncommunicable diseases’ (Bulletin

World Health Organization, 2019 Feb 1; 97(2): 108–117) <https://www.ncbi.nlm.nih.gov/pmc/

articles/PMC6357565/> Accessed 21 April 2023.

28

The Burden of Noncommunicable Diseases and the Current State of Noncommunicable

Disease Prevention Regulation in the Caribbean

of the Caribbean Public Health Law Forum jointly by PAHO and the Caribbean

Court of Justice Academy for Law in 2021, with the support of the CARICOM

Secretariat, the University of the West Indies Cave Hill campus, Law and Health

Research Unit and the Healthy Caribbean Coalition, provides a platform for the

development of the capacities of the legal profession and public health professionals

through shared country experience and technical expertise.

The Caribbean is well poised to develop and implement evidence-based, robust

public health laws for NCDs. The growing political determination, increased domestic

and international support and the opportunity to leverage lessons learnt from the

COVID-19 response, oer hope for progress. Countries will need to ensure that

they strengthen mechanisms to protect against vested interest that may hinder

development of legal measures to prevent NCDs.

Whilst not addressed in this article, it will also be important that as Caribbean

countries advance eorts to regulate NCD prevention that they invest in comprehensive

social marketing campaigns that can garner and reenforce public support for these

interventions and counter any misinformation.