Category Archives: tobacco

Why doesn’t evidence win the day in policy and policymaking?

cairney-southampton-evidence-win-the-dayPolitics has a profound influence on the use of evidence in policy, but we need to look ‘beyond the headlines’ for a sense of perspective on its impact.

It is tempting for scientists to identify the pathological effect of politics on policymaking, particularly after high profile events such as the ‘Brexit’ vote in the UK and the election of Donald Trump as US President. We have allegedly entered an era of ‘post-truth politics’ in which ideology and emotion trumps evidence and expertise (a story told many times at events like this), particularly when issues are salient.

Yet, most policy is processed out of this public spotlight, because the flip side of high attention to one issue is minimal attention to most others. Science has a crucial role in this more humdrum day-to-day business of policymaking which is far more important than visible. Indeed, this lack of public visibility can help many actors secure a privileged position in the policy process (and further exclude citizens).

In some cases, experts are consulted routinely. There is often a ‘logic’ of consultation with the ‘usual suspects’, including the actors most able to provide evidence-informed advice. In others, scientific evidence is often so taken for granted that it is part of the language in which policymakers identify problems and solutions.

In that context, we need better explanations of an ‘evidence-policy’ gap than the pathologies of politics and egregious biases of politicians.

To understand this process, and appearance of contradiction between excluded versus privileged experts, consider the role of evidence in politics and policymaking from three different perspectives.

The perspective of scientists involved primarily in the supply of evidence

Scientists produce high quality evidence only for politicians often ignore it or, even worse, distort its message to support their ideologically-driven policies. If they expect ‘evidence-based policymaking’ they soon become disenchanted and conclude that ‘policy-based evidence’ is more likely. This perspective has long been expressed in scientific journals and commentaries, but has taken on new significance following ‘Brexit’ and Trump.

The perspective of elected politicians

Elected politicians are involved primarily in managing government and maximising public and organisational support for policies. So, scientific evidence is one piece of a large puzzle. They may begin with a manifesto for government and, if elected, feel an obligation to carry it out. Evidence may play a part in that process but the search for evidence on policy solutions is not necessarily prompted by evidence of policy problems.

Further, ‘evidence based policy’ is one of many governance principles that politicians should feel the need to juggle. For example, in Westminster systems, ministers may try to delegate policymaking to foster ‘localism’ and/ or pragmatic policymaking, but also intervene to appear to be in control of policy, to foster a sense of accountability built on an electoral imperative. The likely mix of delegation and intervention seems almost impossible to predict, and this dynamic has a knock-on effect for evidence-informed policy. In some cases, central governments roll out the same basic policy intervention and limit local discretion; in others, it identifies broad outcomes and invites other bodies to gather evidence on how best to meet them. These differences in approach can have profound consequences on the models of evidence-informed policy available to us (see the example of Scottish policymaking).

Political science and policy studies provide a third perspective

Policy theories help us identify the relationship between evidence and policy by showing that a modern focus on ‘evidence-based policymaking’ (EBPM) is one of many versions of the same fairy tale – about ‘rational’ policymaking – that have developed in the post-war period. We talk about ‘bounded rationality’ to identify key ways in which policymakers or organisations could not achieve ‘comprehensive rationality’:

  1. They cannot separate values and facts.
  2. They have multiple, often unclear, objectives which are difficult to rank in any meaningful way.
  3. They have to use major shortcuts to gather a limited amount of information in a limited time.
  4. They can’t make policy from the ‘top down’ in a cycle of ordered and linear stages.

Limits to ‘rational’ policymaking: two shortcuts to make decisions

We can sum up the first three bullet points with one statement: policymakers have to try to evaluate and solve many problems without the ability to understand what they are, how they feel about them as a whole, and what effect their actions will have.

To do so, they use two shortcuts: ‘rational’, by pursuing clear goals and prioritizing certain kinds and sources of information, and ‘irrational’, by drawing on emotions, gut feelings, deeply held beliefs, habits, and the familiar to make decisions quickly.

Consequently, the focus of policy theories is on the links between evidence, persuasion, and framing issues to produce or reinforce a dominant way to define policy problems. Successful actors combine evidence and emotional appeals or simple stories to capture policymaker attention, and/ or help policymakers interpret information through the lens of their strongly-held beliefs.

Scientific evidence plays its part, but scientists often make the mistake of trying to bombard policymakers with evidence when they should be trying to (a) understand how policymakers understand problems, so that they can anticipate their demand for evidence, and (b) frame their evidence according to the cognitive biases of their audience.

Policymaking in ‘complex systems’ or multi-level policymaking environments

Policymaking takes place in less ordered, less hierarchical, and less predictable environment than suggested by the image of the policy cycle. Such environments are made up of:

  1. a wide range of actors (individuals and organisations) influencing policy at many levels of government
  2. a proliferation of rules and norms followed by different levels or types of government
  3. close relationships (‘networks’) between policymakers and powerful actors
  4. a tendency for certain beliefs or ‘paradigms’ to dominate discussion
  5. shifting policy conditions and events that can prompt policymaker attention to lurch at short notice.

These five properties – plus a ‘model of the individual’ built on a discussion of ‘bounded rationality’ – make up the building blocks of policy theories (many of which I summarise in 1000 Word posts). I say this partly to aid interdisciplinary conversation: of course, each theory has its own literature and jargon, and it is difficult to compare and combine their insights, but if you are trained in a different discipline it’s unfair to ask you devote years of your life to studying policy theory to end up at this point.

To show that policy theories have a lot to offer, I have been trying to distil their collective insights into a handy guide – using this same basic format – that you can apply to a variety of different situations, from explaining painfully slow policy change in some areas but dramatic change in others, to highlighting ways in which you can respond effectively.

We can use this approach to help answer many kinds of questions. With my Southampton gig in mind, let’s use some examples from public health and prevention.

Why doesn’t evidence win the day in tobacco policy?

My colleagues and I try to explain why it takes so long for the evidence on smoking and health to have a proportionate impact on policy. Usually, at the back of my mind, is a public health professional audience trying to work out why policymakers don’t act quickly or effectively enough when presented with unequivocal scientific evidence. More recently, they wonder why there is such uneven implementation of a global agreement – the WHO Framework Convention on Tobacco Control – that almost every country in the world has signed.

We identify three conditions under which evidence will ‘win the day’:

  1. Actors are able to use scientific evidence to persuade policymakers to pay attention to, and shift their understanding of, policy problems. In leading countries, it took decades to command attention to the health effects of smoking, reframe tobacco primarily as a public health epidemic (not an economic good), and generate support for the most effective evidence-based solutions.
  2. The policy environment becomes conducive to policy change. A new and dominant frame helps give health departments (often in multiple venues) a greater role; health departments foster networks with public health and medical groups at the expense of the tobacco industry; and, they emphasise the socioeconomic conditions – reductions in smoking prevalence, opposition to tobacco control, and economic benefits to tobacco – supportive of tobacco control.
  3. Actors exploit ‘windows of opportunity’ successfully. A supportive frame and policy environment maximises the chances of high attention to a public health epidemic and provides the motive and opportunity of policymakers to select relatively restrictive policy instruments.

So, scientific evidence is a necessary but insufficient condition for major policy change. Key actors do not simply respond to new evidence: they use it as a resource to further their aims, to frame policy problems in ways that will generate policymaker attention, and underpin technically and politically feasible solutions that policymakers will have the motive and opportunity to select. This remains true even when the evidence seems unequivocal and when countries have signed up to an international agreement which commits them to major policy change. Such commitments can only be fulfilled over the long term, when actors help change the policy environment in which these decisions are made and implemented. So far, this change has not occurred in most countries (or, in other aspects of public health in the UK, such as alcohol policy).

Why doesn’t evidence win the day in prevention and early intervention policy?

UK and devolved governments draw on health and economic evidence to make a strong and highly visible commitment to preventive policymaking, in which the aim is to intervene earlier in people’s lives to improve wellbeing and reduce socioeconomic inequalities and/ or public sector costs. This agenda has existed in one form or another for decades without the same signs of progress we now associate with areas like tobacco control. Indeed, the comparison is instructive, since prevention policy rarely meets the three conditions outlined above:

  1. Prevention is a highly ambiguous term and many actors make sense of it in many different ways. There is no equivalent to a major shift in problem definition for prevention policy as a whole, and little agreement on how to determine the most effective or cost-effective solutions.
  2. A supportive policy environment is far harder to identify. Prevention policy cross-cuts many policymaking venues at many levels of government, with little evidence of ‘ownership’ by key venues. Consequently, there are many overlapping rules on how and from whom to seek evidence. Networks are diffuse and hard to manage. There is no dominant way of thinking across government (although the Treasury’s ‘value for money’ focus is key currency across departments). There are many socioeconomic indicators of policy problems but little agreement on how to measure or which measures to privilege (particularly when predicting future outcomes).
  3. The ‘window of opportunity’ was to adopt a vague solution to an ambiguous policy problem, providing a limited sense of policy direction. There have been several ‘windows’ for more specific initiatives, but their links to an overarching policy agenda are unclear.

These limitations help explain slow progress in key areas. The absence of an unequivocal frame, backed strongly by key actors, leaves policy change vulnerable to successful opposition, especially in areas where early intervention has major implications for redistribution (taking from existing services to invest in others) and personal freedom (encouraging or obliging behavioural change). The vagueness and long term nature of policy aims – to solve problems that often seem intractable – makes them uncompetitive, and often undermined by more specific short term aims with a measurable pay-off (as when, for example, funding for public health loses out to funding to shore up hospital management). It is too easy to reframe existing policy solutions as preventive if the definition of prevention remains slippery, and too difficult to demonstrate the population-wide success of measures generally applied to high risk groups.

What happens when attitudes to two key principles – evidence based policy and localism – play out at the same time?

A lot of discussion of the politics of EBPM assumes that there is something akin to a scientific consensus on which policymakers do not act proportionately. Yet, in many areas – such as social policy and social work – there is great disagreement on how to generate and evaluate the best evidence. Broadly speaking, a hierarchy of evidence built on ‘evidence based medicine’ – which has randomised control trials and their systematic review at the top, and practitioner knowledge and service user feedback at the bottom – may be completely subverted by other academics and practitioners. This disagreement helps produce a spectrum of ways in which we might roll-out evidence based interventions, from an RCT-driven roll-out of the same basic intervention to a storytelling driven pursuit of tailored responses built primarily on governance principles (such as to co-produce policy with users).

At the same time, governments may be wrestling with their own governance principles, including EBPM but also regarding the most appropriate balance between centralism and localism.

If you put both concerns together, you have a variety of possible outcomes (and a temptation to ‘let a thousand flowers bloom’) and a set of competing options (outlined in table 1), all under the banner of ‘evidence based’ policymaking.

Table 1 Three ideal types EBBP

What happens when a small amount of evidence goes a very long way?

So, even if you imagine a perfectly sincere policymaker committed to EBPM, you’d still not be quite sure what they took it to mean in practice. If you assume this commitment is a bit less sincere, and you add in the need to act quickly to use the available evidence and satisfy your electoral audience, you get all sorts of responses based in some part on a reference to evidence.

One fascinating case is of the UK Government’s ‘troubled families’ programme which combined bits and pieces of evidence with ideology and a Westminster-style-accountability imperative, to produce:

  • The argument that the London riots were caused by family breakdown and bad parenting.
  • The use of proxy measures to identify the most troubled families
  • The use of superficial performance management to justify notionally extra expenditure for local authorities
  • The use of evidence in a problematic way, from exaggerating the success of existing ‘family intervention projects’ to sensationalising neuroscientific images related to brain development in deprived children …

normal brain

…but also

In other words, some governments feel the need to dress up their evidence-informed policies in a language appropriate to Westminster politics. Unless we understand this language, and the incentives for elected policymakers to use it, we will fail to understand how to act effectively to influence those policymakers.

What can you do to maximise the use of evidence?

When you ask the generic question you can generate a set of transferable strategies to engage in policymaking:

how-to-be-heard

ebpm-5-things-to-do

Yet, as these case studies of public health and social policy suggest, the question lacks sufficient meaning when applied to real world settings. Would you expect the advice that I give to (primarily) natural scientists (primarily in the US) to be identical to advice for social scientists in specific fields (in, say, the UK)?

No, you’d expect me to end with a call for more research! See for example this special issue in which many scholars from many disciplines suggest insights on how to maximise the use of evidence in policy.

Palgrave C special

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Filed under Evidence Based Policymaking (EBPM), Prevention policy, Public health, public policy, tobacco, tobacco policy

Writing an essay on politics, policymaking, and policy change

I tend to set this simple-looking question for coursework in policy modules: what is policy, how much has it changed, and why? Students get to choose the policy issue, timeframe (and sometimes the political system), and relevant explanatory concepts.

On the face of it, it looks super-simple: A+ for everyone!

Give it a few more seconds, and you can see the difficulties:

  1. We spent a lot of time agreeing that it seems almost impossible to define policy (explained in 1000 Words and 500 Words)
  2. There are a gazillion possible measures of policy change (1000 Words and 500 Words)
  3. There is an almost unmanageable number of models, concepts, and theories to use to explain policy dynamics (I describe about 25 in 1000 Words each)

I try to encourage some creativity when solving this problem, but also advise students to keep their discussion as simple and jargon-free as possible (often by stretching an analogy with diving, in which a well-executed simple essay can score higher than a belly-flopped hard essay).

Choosing a format: the initial advice

  1. Choose a policy area (such as health) or issue (such as alcohol policy).
  2. Describe the nature of policy, and the extent of policy change, in a particular time period (such as in the post-war era, since UK devolution, or since a change in government).
  3. Select one or more policy concept or theory to help structure your discussion and help explain how and why policy has changed.

For example, a question might be: What is tobacco policy in the UK, how much has it changed since the 1980s, and why? I use this example because I try to answer that – UK and global – question myself, even though my 2007 article on the UK is too theory-packed to be a good model for an undergraduate essay.

Choosing a format: the cautionary advice

You may be surprised about how difficult it is to answer a simple question like ‘what is policy?’ and I will give you considerable credit for considering how to define and measure it, by identifying, for example, the use of legislation/ regulation, funding, staff, and ‘nodality’ and/ or by considering the difference between, say, policy as a statement of intent or a long term outcome. In turn, a good description and explanation of policy change is difficult. If you are feeling ambitious, you can go further, to compare, say, two issues (such as tobacco and alcohol) or places (such UK Government policy and the policy of another country), but sometimes a simple and narrow discussion can be as, or more, effective. Similarly, you can use many theories or concepts to aid explanation, but often one theory will do. Note that (a) your description of your research question, and your essay structure, is more important than (b) your decision on what topic to focus or concepts to use.

Choosing a topic: the ‘joined up’ advice

The wider aim is to encourage students to think about the relationship between different perspectives on policy theory and analysis. For example, in a blog and policy analysis paper they try to generate attention to a policy problem and advocate a solution. Then, they draw on policy theories and concepts to reflect on their papers, highlighting (say): the need to identify the most important audience; the importance of framing issues with a mixture of evidence and emotional appeals; and, the need to present ‘feasible’ solutions.

The reflection can provide a useful segue to the essay, since we’re already identifying important policy problems, advocating change, reflecting on how best to encourage it – such as by presenting modest objectives – and then, in the essay, trying to explain (say) why governments have not taken that advice in the past. Their interest in the policy issue can prompt interest in researching the issue further; their knowledge of the issue and the policy process can help them develop politically-aware policy analysis. All going well, it produces a virtuous circle.

Some examples from my pet subject

Let me outline how I would begin to answer the three questions with reference to UK tobacco policy. I’m offering a brief summary of each section rather than presenting a full essay with more detail (partly to hold on to that idea of creativity – I don’t want students to use this description as a blueprint).

What is modern UK tobacco policy?

Tobacco policy in the UK is now one of the most restrictive in the world. The UK government has introduced a large number of policy instruments to encourage a major reduction of smoking in the population. They include: legislation to ban smoking in public places; legislation to limit tobacco advertising, promotion, and sponsorship; high taxes on tobacco products; unequivocal health education; regulations on tobacco ingredients; significant spending on customs and enforcement measures; and, plain packaging measures.

[Note that I selected only a few key measures to define policy. A fuller analysis might expand on why I chose them and why they are so important].

How much has policy changed since the 1980s?

Policy has changed radically since the post-war period, and most policy change began from the 1980s, but it was not until the 2000s onwards that the UK cemented its place as one of the most restrictive countries. The shift from the 1980s relates strongly to the replacement of voluntary agreements and limited measures with limited enforcement with legislative measures and stronger enforcement. The legislation to ban tobacco advertising, passed in 2002, replaced limited bans combined with voluntary agreements to (for example) keep billboards a certain distance from schools. The legislation to ban smoking in public places, passed in 2006 (2005 in Scotland), replaced voluntary measures which allowed smoking in most pubs and restaurants. Plain packaging measures, combined with large and graphic health warnings, replace branded packets which once had no warnings. Health education warnings have gone from stating the facts and inviting smokers to decide, and the promotion of harm reduction (smoke ‘low tar’), to an unequivocal message on the harms of smoking and passive smoking.

[Note that I describe these changes in broad terms. Other articles might ‘zoom’ in on specific instruments to show how exactly they changed]

Why has it changed?

This is the section of the essay in which we have to make a judgement about the type of explanation: should you choose one or many concepts; if many, do you focus on their competing or complementary insights; should you provide an extensive discussion of your chosen theory?

I normally recommend a very small number of concepts or simple discussion, largely because there is only so much you can say in an essay of 2-3000 words.

For example, a simple ‘hook’ is to ask if the main driver was the scientific evidence: did policy change as the evidence on smoking (and then passive smoking) related harm became more apparent? Is it a good case of ‘evidence based policymaking’? The answer may then note that policy change seemed to be 20-30 years behind the evidence [although I’d have to explain that statement in more depth] and set out the conditions in which this driver would have an effect.

In short, one might identify the need for a ‘policy environment’, shaped by policymakers, and conducive to a strong policy response based on the evidence of harm and a political choice to restrict tobacco use. It would relate to decisions by policymakers to: frame tobacco as a public health epidemic requiring a major government response (rather than primarily as an economic good or issue of civil liberties); place health departments or organisations at the heart of policy development; form networks with medical and public health groups at the expense of tobacco companies; and respond to greater public support for control, reduced smoking prevalence, and the diminishing economic value of tobacco.

This discussion can proceed conceptually, in a relatively straightforward way, or with the further aid of policy theories which ask further questions and help structure the answers.

For example, one might draw on punctuated equilibrium theory to help describe and explain shifts of public/media/ policymaker attention to tobacco, from low and positive in the 1950s to high and negative from the 1980s.

Or, one might draw on the ACF to explain how pro-tobacco coalitions helped slow down policy change by interpreting new scientific evidence though the ‘lens’ of well-established beliefs or approaches (examples from the 1950s include filter tips, low tar brands, and ventilation as alternatives to greater restrictions on smoking).

One might even draw on multiple streams analysis to identify a ‘window of opportunity for change (as I did when examining the adoption of bans on smoking in public places).

Any of these approaches will do, as long as you describe and justify your choice well. One cannot explain everything, so it may be better to try to explain one thing well.

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Filed under 1000 words, 500 words, POLU9UK, tobacco, tobacco policy, UK politics and policy

What does it take to turn scientific evidence into policy? Lessons for illegal drugs from tobacco

This post contains preliminary notes for my keynote speech ‘The politics of evidence-based policymaking’ for the COPOLAD annual conference, ‘From evidence to practice: challenges in the field of drugs policies’ (14th June). I may amend them in the run up to the speech (and during their translation into Spanish).

COPOLAD (Cooperation Programme on Drugs Policies) is a ‘partnership cooperation programme between the European Union, Latin America and the Caribbean countries aiming at improving the coherence, balance and impact of drugs policies, through the exchange of mutual experiences, bi-regional coordination and the promotion of multisectoral, comprehensive and coordinated responses’. It is financed by the EU.

My aim is to draw on policy studies, and the case study of tobacco/ public health policy, to identify four lessons:

  1. ‘Evidence-based policymaking’ is difficult to describe and understand, but we know it’s a highly political process which differs markedly from ‘evidence based medicine’.
  2. Actors focus as much on persuasion to reduce ambiguity as scientific evidence to reduce uncertainty. They also develop strategies to navigate complex policymaking ‘systems’ or ‘environments’.
  3. Tobacco policy demonstrates three conditions for the proportionate uptake of evidence: it helps ‘reframe’ a policy problem; it is used in an environment conducive to policy change; and, policymakers exploit ‘windows of opportunity’ for change.
  4. Even the ‘best cases’ of tobacco control highlight a gap of 20-30 years between the production of scientific evidence and a proportionate policy response. In many countries it could be 50. I’ll use this final insight to identify some scenarios on how evidence might be used in areas, such as drugs policy, in which many of the ‘best case’ conditions are not met.

‘Evidence-based policymaking’ is highly political and difficult to understand

Evidence-based policymaking (EBPM) is so difficult to understand that we don’t know how to define it or each word in it! People use phrases like ‘policy-based evidence’, to express cynicism about the sincere use of evidence to guide policy, or ‘evidence informed policy’, to highlight its often limited impact. It is more important to try to define each element of EBPM – to identify what counts as evidence, what is policy, who are the policymakers, and what an ‘evidence-based’ policy would look like – but this is easier said than done.

In fact, it is far easier to say what EBPM is not:

It is not ‘comprehensively rational’

Comprehensive rationality’ describes, in part, the absence of ambiguity and uncertainty:

  • Policymakers translate their values into policy in a straightforward manner – they know what they want and about the problem they seek to solve.
  • Policymakers and governments can gather and understand all information required to measure the problem and determine the effectiveness of solutions.

Instead, we talk of ‘bounded rationality’ and how policymakers deal with it. They employ two kinds of shortcut: ‘rational’, by pursuing clear goals and prioritizing certain kinds and sources of information, and ‘irrational’, by drawing on emotions, gut feelings, deeply held beliefs, habits, and what is familiar to them, to make decisions quickly.

It does not take place in a policy cycle with well-ordered stages

Policy cycle’ describes the ides that there is a core group of policymakers at the ‘centre’, making policy from the ‘top down’, and pursuing their goals in a series of clearly defined and well-ordered stages, such as: agenda setting, policy formulation, legitimation, implementation, and evaluation.

It does not describe or explain policymaking well. Instead, we tend to identify the role of environments or systems.

When describing less ordered and predictable policy environments, we describe:

  • a wide range of actors (individuals and organisations) influencing policy at many levels of government
  • a proliferation of rules and norms followed by different levels or types of government
  • important relationships (‘networks’) between policymakers and powerful actors (with material resources, or the ability to represent a profession or social group)
  • a tendency for certain ‘core beliefs’ or ‘paradigms’ to dominate discussion
  • shifting policy conditions and events that can prompt policymaker attention to lurch at short notice.

When describing complex policymaking systems we show that, for example, (a) the same inputs of evidence or policy activity can have no, or a huge, effect, and (b) policy outcomes often ‘emerge’ in the absence of central government control (which makes it difficult to know how, and to whom, to present evidence or try to influence).

It does not resemble ‘evidence based medicine’ or the public health culture

In health policy we can identify an aim, associated with ‘evidence-based medicine’ (EBM), to:

(a) gather the best evidence on the effectiveness of policy interventions, based on a hierarchy of research methods which favours, for example, the systematic review of randomised control trials (RCTs)

(b) ensure that this evidence has a direct impact on healthcare and public health, to exhort practitioners to replace bad interventions with good, as quickly as possible.

Instead, (a) policymakers can ignore the problems raised by scientific evidence for long periods of time, only for (b) their attention to lurch, prompting them to beg, borrow, or steal information quickly from readily available sources. This can involve many sources of evidence (such as the ‘grey literature’) that some scientists would not describe as reliable.

Actors focus as much on persuasion to reduce ambiguity as scientific evidence to reduce uncertainty.

In that context, ‘evidence-based policymaking’ is about framing problems and adapting to complexity.

Framing refers to the ways in which policymakers understand, portray, and categorise issues. Problems are multi-faceted, but bounded rationality limits the attention of policymakers, and actors compete to highlight one ‘image’ at the expense of others. The outcome of this process determines who is involved (for example, portraying an issue as technical limits involvement to experts), who is responsible for policy, how much attention they pay, their demand for evidence on policy solutions, and what kind of solution they favour.

Scientific evidence plays a part in this process, but we should not exaggerate the ability of scientists to win the day with reference to evidence. Rather, policy theories signal the strategies that actors adopt to increase demand for their evidence:

  • to combine facts with emotional appeals, to prompt lurches of policymaker attention from one policy image to another (punctuated equilibrium theory)
  • to tell simple stories which are easy to understand, help manipulate people’s biases, apportion praise and blame, and highlight the moral and political value of solutions (narrative policy framework)
  • to interpret new evidence through the lens of the pre-existing beliefs of actors within coalitions, some of which dominate policy networks (advocacy coalition framework)
  • to produce a policy solution that is feasible and exploit a time when policymakers have the opportunity to adopt it (multiple streams analysis).

This takes place in complex ‘systems’ or ‘environments’

A focus on this bigger picture shifts our attention from the use of evidence by an elite group of elected policymakers at the ‘top’ to its use by a wide range of influential actors in a multi-level policy process. It shows actors that:

  • They are competing with many others to present evidence in a particular way to secure a policymaker audience.
  • Support for particular solutions varies according to which organisation takes the lead and how it understands the problem.
  • Some networks are close-knit and difficult to access because bureaucracies have operating procedures that favour particular sources of evidence and some participants over others
  • There is a language – indicating which ideas, beliefs, or ways of thinking are most accepted by policymakers and their stakeholders – that takes time to learn.
  • Well-established beliefs provide the context for policymaking: new evidence on the effectiveness of a policy solution has to be accompanied by a shift of attention and successful persuasion.
  • In some cases, social or economic ‘crises’ can prompt lurches of attention from one issue to another, and some forms of evidence can be used to encourage that shift. However, major policy shifts are rare.

In other words, successful actors develop pragmatic strategies based on the policy process that exists, not the process they’d like to see

We argue that successful actors: identify where the ‘action is’ (in networks and organisations in several levels of government); learn and follow the ‘rules of the game’ within networks to improve strategies and help build up trust; form coalitions with actors with similar aims and beliefs; and, frame the evidence to appeal to the biases, beliefs, and priorities of policymakers.

Tobacco policy demonstrates three conditions for the proportionate uptake of evidence

Case studies allow us to turn this general argument into insights generated from areas such as public health.

There are some obvious and important differences between tobacco and (illegal) drugs policies, but an initial focus on tobacco allows us to consider the conditions that might have to be met to use the best evidence on a problem to promote (what we consider to be) a proportionate and effective solution.

We can then use the experience of a ‘best case scenario’ to identify the issues that we face in less ideal circumstances (first in tobacco, and second in drugs).

With colleagues, I have been examining:

Our studies help us identify the conditions under which scientific evidence, on the size of the tobacco problem and the effectiveness of solutions, translates into a public policy response that its advocates would consider to be proportionate.

  1. Actors are able to use scientific evidence to persuade policymakers to pay attention to, and shift their understanding of, policy problems.

Although scientific evidence helps reduce uncertainty, it does not reduce ambiguity. Rather, there is high competition to define problems, and the result of this competition helps determine the demand for subsequent evidence.

In tobacco, the evidence on smoking and then passive smoking helped raise attention to public health, but it took decades to translate into a proportionate response, even in ‘leading’ countries such as the UK.

The comparison with ‘laggard’ countries is crucial to show that the same evidence can produce a far more limited response, as policymakers compare the public health imperative with other ‘frames’, relating to their beliefs on personal responsibility, civil liberties, and the economic consequences of tobacco controls.

  1. The policy environment becomes conducive to policy change.

Public health debates take place in environments more or less conducive to policy change. In the UK, actors used scientific evidence to help reframe the problem. Then, this new understanding helped give the Department of Health a greater role, the health department fostered networks with public health and medical groups at the expense of the industry and, while pursuing policy change, policymakers emphasised the reduced opposition to tobacco control, smoking prevalence, and economic benefits to tobacco,.

In many other countries, these conditions are far less apparent: there are multiple tobacco frames (including economic and civil liberties); economic and trade departments are still central to policy; the industry remains a key player; and, policymakers pay more attention to opposition to tobacco controls (such as bans on smoking in public places) and their potential economic consequences.

Further, differences between countries have largely endured despite the fact that most countries are parties to the FCTC. In other words, a commitment to evidence basedpolicy transfer’ does not necessarily produce actual policy change.

  1. Actors generate and exploit ‘windows of opportunity’ for major policy change.

Even in favourable policy environments, it is not inevitable that major policy changes will occur. Rather, the UK’s experience of key policy instruments – such as legislation to ban smoking in public places (a major commitment of the FCTC) – shows the high level of serendipity involved in the confluence of three necessary but insufficient conditions:

  1. high policymaker attention to tobacco as a policy problem
  2. the production of solutions, introducing partial or comprehensive bans on smoking in public places, that are technically and politically feasible
  3. the willingness and ability of policymakers to choose the more restrictive solution.

In many other countries, there has been no such window of opportunity, or only an opportunity for a far weaker regulation.

So, this condition – the confluence of three ‘streams’ during a ‘window of opportunity’ – shows the major limits to the effect of scientific evidence. The evidence on the health effects of passive smoking have been available since the 1980s, but they only contributed to comprehensive smoking bans in the UK in the mid-2000s, and they remain unlikely in many other countries.

Comparing ‘best case’ and ‘worst case’ scenarios for policy change

These discussions help us clarify the kinds of conditions that need to be met to produce major ‘evidence based’ policy change, even when policymakers have made a commitment to it, or are pursuing an international agreement.

I provide a notional spectrum of ‘best’ and ‘worst’ case scenarios in relation to these conditions:

  1. Actors agree on how to gather and interpret scientific evidence.
  • Best case: governments fund effective ways to gather and interpret the most relevant evidence on the size of policy problems and the effectiveness of solutions. Policymakers can translate large amounts of evidence on complex situations into simple and effective stories (that everyone can understand) to guide action. This includes evidence of activity in one’s own country, and of transferable success from others.
  • Worst case: governments do not know the size of the problem or what solutions have the highest impacts. They rely on old stories that reinforce ineffective action, and do not know how to learn from the experience of other regions (note the ‘not invented hereissue).
  1. Actors ‘frame’ the problem simply and/or unambiguously.
  • Best case: governments maintain a consensus on how best to understand the cause of a policy problem and therefore which evidence to gather and solutions to seek.
  • Worst case: governments juggle many ‘frames’, there is unresolved competition to define the problem, and the best sources of evidence and solutions remain unclear.
  1. A new policy frame is not undermined by the old way of thinking about, and doing, things
  • Best case: the new frame sets the agenda for actors in existing organisations and networks; there is no inertia linked to the old way of thinking about and doing things.
  • Worst case: there is a new policy, but it is undermined by old beliefs, rules, pre-existing commitments (for example, we talk of ‘path dependence’ and ‘inheritance before choice’), or actors opposed to the new policy.
  1. There is a clear ‘delivery chain’ from policy choice to implementation
  • Best case: policymakers agree on a solution, they communicate their aims well, and they secure the cooperation of the actors crucial to policy delivery in many levels and types of government.
  • Worst case: policymakers communicate an ambiguous message and/ or the actors involved in policy delivery pursue different – and often contradictory – ways to try to solve the same problem.

In international cooperation, it is natural to anticipate and try to minimise at least some of these worst case scenarios. Problems are more difficult to solve when they are transnational. Our general sense of uncertainty and complexity is more apparent when there are many governments involved and we cannot rely on a single authoritative actor to solve problems. Each country (and regions within it) has its own beliefs and ways of doing things, and it is not easy to simply emulate another country (even if we think it is successful and know why). Some countries do not have access to the basic information (for example, on health and mortality, alongside statistics on criminal justice) that others take for granted when they monitor the effectiveness of policies.

Further, these obstacles exist in now-relatively-uncontroversial issues, such as tobacco, in which there is an international consensus on the cause of the problem and the appropriateness and effectiveness of public solutions. It is natural to anticipate further problems when we also apply public health (and, in this case, ‘harm reduction’) measures to more controversial areas such as illegal drugs.

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Why do people seem so down on e-cigs?

It must be very frustrating to give up smoking, with the help of e-cigarettes, only to find that you are no more welcome in public places with a fake cigarette than a real one. UK governments, and many public health advocates, often seem to want to regulate them in the same way, even though the e-cig could be described as a crucial ‘harm reduction’ measure (it’s not exactly healthy, but it’s much better than the other thing you were doing).

Here is a list of historical explanations for this position which won’t make you happy, but can at least distract you while you’re having a sly puff in the toilets:

  1. We’ve been here before with tobacco and harm reduction. So many post-war examples – like the idea of smoking a pipe, putting filter tips on cigarettes, ‘low tar’ cigarettes (which is a bit like ‘less shite in your sandwich’), and ventilators in public spaces – suggest that ‘harm reduction’ (combined with cheeky advertising) represents a way for members of the tobacco industry to keep people doing what they are doing and avoid government regulation. Someone who has spent decades of their time challenging the industry will see this as just another wheeze.
  2. Harm reduction has long been rejected in tobacco control. The thing you can hang your hat on is that there is no safe level of smoking – which, since the 1970s/80s has influenced the UK public health message.  It’s now very difficult to incorporate a harm reduction message into a field built on a push for abstention – particularly when we don’t yet know how much harm we are reducing.
  3. Denormalisation. The same goes for the idea of ‘denormalisation’, which describes a series of policy instruments to challenge the idea that smoking is a normal part of public life. Maybe if a bunch of people start puffing away at things that look like mini-bongs instead of imitation cigarettes, that will change – but we’d encourage that shift on the basis of hope. Further, and more importantly, some tobacco companies are getting into the e-cig business and branding them in similar ways to real-cigs. So, for example, the government wouldn’t want to go to the trouble of plain-packaging and hiding cigarettes on the supermarket shelves only to allow a tobacco company to put up a huge branded display for its e-cigs right next to the real ones. If this is really about harm reduction, for some it means getting a utilitarian-looking bit of plastic and a pea-flavoured mix from a pharmacy.
  4. The politics of evidence-based policy making. Advocates of e-cig control are playing a clever game, arguing that the only way to know the long term effects of e-cigarettes is to distribute them in a controlled environment, to gather data on their use and effects. The argument is: if an e-cig is medicine, let’s regulate it like any other medicine. You can see why this argument would trump others: we’re all biased, and rely on cherry-picked evidence on their effects, or we point to experts that support our position; but, you’d struggle to trump the medical profession when getting together a posse of experts (recommending systematic evidence-based medicine).
  5. We trust doctors more than tobacco companies. The image of doctors remains of the people on the front line, able to see the damaging effects of unhealthy behaviour. The image of tobacco companies is more likely to relate to the idea that some of them maybe sort-of lied to the US senate about their harmful effects. So, it will always be possible to argue that e-cig advocates are doing the bidding of the tobacco companies. Don’t blame the doctors, blame the companies.
  6. We could see this as a cover for ‘Big Pharma’, trying to make a tonne of money from the NHS from smoking cessation services –  but that’s a difficult argument to make stick when the even less popular ‘Big Tobacco’ seems to be trying to diversify into e-cigs, and use the same branding as it uses for r-cigs.
  7. Demonising the companies, not the smokers. The vast majority of governments across the globe have made a commitment to cutting ties with the tobacco industry (which includes not consulting with the industry on public policy) and will be looking for ways to sort-of encourage e-cigs over r-cigs and bypass a reliance on the old industry.

Overall, maybe some of this new agenda is driven by people who see the benefit of temperance and like to tell you what to do and where to do it – but, even if there were no ‘new puritans’, you’d still have these problems about what to do when a new e-cig opportunity rubs up the wrong way against well-established tobacco control policy.

See also: Linda Bauld ‘There’s no evidence e-cigarettes are as harmful as smoking’

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Tobacco Control in South Korea (A ‘War on Tobacco’?)

I did a short radio interview today, prompted by developments in tobacco control in South Korea, including a doubling of tobacco prices and the introduction of new regulations in 2015. I’ll put up the audio soon, and here are my notes on the questions. As usual, with this topic, it is difficult to present these things in a ‘neutral’ language when talking about how ‘leading’ or ‘lax’ some countries are.

Interview Questions tbs efm Primetime (Seoul, South Korea) 5.1.15 6.40pm (9.40am)

Q1. In your view, what makes some countries lax in regulating smoking? 

  • Imagine two processes
  1. Almost all have signed up to tobacco control – the World Health Organisation-led Framework Convention on Tobacco Control
  2. But many countries face more obstacles when they try to turn that commitment into something fully implemented
  • Their ‘environments are not conducive to tobacco control

5 factors involved:

  1. Defining the problem – economic or public health?
  2. Institutions – is the department of health in charge?
  3. Networks – do policymakers exclude tobacco companies from policymaking?
  4. Socioeconomic – what is smoking prevalence? Public attitudes? Contribution to the economy?
  5. Ideas – how much of the evidence is accepted in government (smoking, passive smoking) in a meaningful way.

The answer to those Qs is very different in ‘leading’ and ‘laggard’ countries.

See: https://paulcairney.wordpress.com/public-health/

Q2. How can the gap between the evidence of a major problem and a proportionate response be narrowed?

  • The answer, for most countries, is to implement the FCTC they signed up to
  • FCTC measures include:
  1. Tobacco taxation policy – price and tax measures to reduce demand for tobacco
  2. Smoke-free policy – protection from exposure to secondhand smoke
  3. Tobacco product regulation – regulation of contents of products (toxic ingredients)
  4. Ingredient disclosure – regulation of public tobacco product disclosures
  5. Health warning labels – at least 30% of the package of tobacco products should be a health warning
  6. Education and advocacy – to improve health education, communication, training and public awareness
  7. Banning tobacco advertising, promotion and sponsorship
  8. Smoking cessation services
  9. Prohibiting the illicit trade in tobacco products
  10. Banning tobacco sales to minors (under 18)
  11. Litigation against tobacco companies
  12. Research to monitor and evaluate tobacco control
  13. Support for economically viable alternatives to tobacco growing

Q3. How would you assess smoking controls in South Korea? 

  • 3 kinds of key context:
  1. When income rises, smoking rates may go up as tobacco becomes more affordable
  2. The shift from (a) smoking being mostly a male activity, with very low rates of smoking among women; to (b) reduced smoking among men, but increased among women, until they converge (as in the UK). Currently its 47% in men and 7% in women (UK now is 21% men, 20% women).

See: http://tobaccocontrol.bmj.com/content/21/2/96.abstract

  1. World trade liberalisation from the 1980s gave tobacco companies the chance to enter new markets See: http://researchonline.lshtm.ac.uk/768502/

Tobacco control may be geared specifically towards addressing those 2 first predictions and the third new issue

  • In short, you might say that South Korea has (a) fewer controls than the UK now, but (b) potentially stronger controls than the UK had when its income levels and smoking rates were comparable
  • g. ‘compliance score’ on smoking in public places is 10/10 for UK and 5/10 for SK (more public places; a fine on owners), more support in the UK for cessation treatment, more health warnings on packs, more bans on advertising, and cigarettes appear to be 3x as expensive in the UK
  • The potential is there to learn from countries with stronger controls while the ‘epidemic’ is less visible

See: http://www.who.int/tobacco/surveillance/policy/country_profile/kor.pdf?ua=1 (SK)

http://www.who.int/tobacco/surveillance/policy/country_profile/gbr.pdf?ua=1 (UK)

Q4. You mentioned in the article you wrote that UK is one of the few countries that has a “comprehensive” tobacco controls. Please explain to us on UK’s main policy instruments designed to reduce smoking in the population. 

  • As above, in regard to FCTC – but UK has mostly gone ahead of it
  • Top of the European ‘Tobacco Control Scale’ (one of 4 leaders) – based on its high prices/ tax, ban on smoking in public places, ban on advertising tobacco in most places, treatment services (smoking cessation/ support) plus health warnings on packs and information campaigns

See: http://www.europeancancerleagues.org/images/TobaccoControl/TCS_2013_in_Europe_13-03-14_final_1.pdf

Q5. Then, what are the international agencies’ efforts to address global tobacco problems so far? 

  • To take that broad commitment to the FCTC, monitor implementation, help spread the evidence on ‘good practice’, help countries fulfil their commitments (and challenge the role of tobacco companies in each country)

Q6. You mentioned that there is a key irony of the WHO’s framework convention on tobacco control. Could you elaborate on that? 

  • One aspect of the FCTC is that it can be used by many countries to avoid the experience of others
  • Countries like the UK are acting because historic smoking rates were high and the problem is highly visible – in smoking-related illnesses – after a significant time lag
  • Countries with historically lower smoking rates (especially among women) could avoid those problems
  • In other words, they stand to benefit most from the FCTC
  • However, they are also, in many cases, far less likely to implement the FCTC
  • The irony is that the countries that could benefit most from the FCTC are often the least likely to act to implement it
  • Many commentators describe this problem in terms of the role of tobacco companies – they see their markets fall in the ‘West’, so they seek markets in the rest of the world; and many countries have limited experience in challenging that behaviour

Q7. At the end of the day what would be the remaining challenges facing the global community to achieve a more cohesive tobacco control policy? 

  • Some countries now talk about smoke-free policies
  • Some focus on challenging the role of tobacco companies – to exclude them from policymaking
  • Some face rising levels of smoking that could possibly be averted
  • The challenge is to recognise how different each country is, and to support tobacco control groups operating in very different policy environments

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Why does public health policy change?

Some public health policies have changed radically in the post-war period. The extent of change varies considerably, from issue to issue, and country to country. For example, the UK has one of the most comprehensive tobacco control regimes in the world, but China does not. While the UK has changed its post-war tobacco policy radically, the same amount of policy change cannot be found in alcohol (or in newer concerns such as sugar, saturated fat and salt in food). While public health policy is often quite similar across the UK, there have been significant differences, in timing and/ or content, in devolved and UK Government policies.

My interest is in the extent to which we explain these developments in (broadly) the same way. With colleagues, Donley Studlar and Hadii Mamudu, I focus on the extent to which actors, in favour of tobacco or alcohol control, operate within a ‘policy environment’ conducive to their aims.

What makes a conducive policy environment?

  1. Institutions. Policymaking responsibility has shifted, to a government department sympathetic to the policy, and following rules which enable its successful delivery.
  2. Networks. The balance of power within departments has shifted in favour of public health and medical, not industry, groups.
  3. Socioeconomics. Social behaviour (e.g. there is a low number of smokers/ drinkers and amount of smoking/ drinking) and attitudes to control have become more in line with policy aims, and there are fewer economic penalties to public health controls (e.g. a loss of tax revenue or economic activity).
  4. Ideas and ‘framing’. There is now an acceptance of the scientific evidence on unhealthy behaviour within government, control is high on its agenda, and it now ‘frames’ the issue in terms of a pressing public health problem (rather than, say, an economic good).

This broad focus can help us explain a range of global, national and subnational developments in public health policy, including:

Global Tobacco Policy

There is a policy environment conducive to tobacco control at a global level – the Framework Convention on Tobacco Control, led by the World Health Organisation – and in many ‘leading’ countries, but not in most countries. Consequently, most countries in the world have signed the FCTC but this is not yet reflected in policy outcomes.

Blog posts and pages:

Global Tobacco Control

The Tobacco ‘Endgame’

The WHO Framework Convention for Tobacco Control (FCTC): What would have to change to ensure effective policy implementation?*

Articles and Book

Hadii Mamudu, Paul Cairney and Donley Studlar (2015) ‘Global Public Policy: does the new venue for transnational tobacco control challenge the old way of doing things?’ forthcoming in Public Administration. ‘Green’ version: Mamudu Cairney Studlar Global Public Policy FCTC 6.11.14

Paul Cairney, Donley Studlar and Haddii Mamudu (2012) Global Tobacco Control: Power, Policy, Governance and Transfer (Basingstoke: Palgrave)

Paul Cairney and Haddii Mamudu (2014) ‘The Global Tobacco Control ‘Endgame’: change the policy environment to implement the FCTC’ Journal of Public Health Policy, Advance Access doi: 10.1057/jphp.2014.18

Donley Studlar and Paul Cairney (2014) ‘Conceptualizing Punctuated and Non-Punctuated Policy Change: Tobacco Control in Comparative Perspective’, International Review of Administrative Sciences, 80, 3, 513-31

UK Tobacco and Alcohol Policy.

UK Tobacco control is now far more comprehensive than alcohol control.

After the War on Tobacco, Is a War on Alcohol Next?*

Alcohol: the Harmful versus Healthy Debate

Why is there more tobacco control policy than alcohol control policy in the UK?

Paul Cairney and Donley Studlar (2014) ‘Public Health Policy in the United Kingdom: After the War on Tobacco, Is a War on Alcohol Brewing?’ World Medical and Health Policy, 6, 3, 308-323

Multi-level Policymaking: tobacco control in EU, UK and devolved government.

Although the EU provides some common standards, they are followed more or less enthusiastically by member states. Although key policies, such as the ban on smoking in public places, exist in all parts of the UK, it is important to explain the ‘window of opportunity’ for policy change in each territory.

Bossman Asare, Paul Cairney and Donley Studlar (2009) ‘Federalism and Multilevel Governance in Tobacco Policy: The European Union, the United Kingdom and the Devolved UK Institutions’, Journal of Public Policy, 29, 1, 79-102 PDF Paywall Green

Paul Cairney (2009) ‘The Role of Ideas in Policy Transfer: The Case of UK Smoking Bans since Devolution’, Journal of European Public Policy, 16, 3, 471-488 PDF Paywall Green

Paul Cairney (2007) ‘A Multiple Lens Approach to Policy Change: the Case of Tobacco Policy in the UK’, British Politics, 2, 1, 45-68 PDF Paywall (plus corrected table) Green

Paul Cairney (2007) ‘Using Devolution to Set the Agenda? Venue shift and the smoking ban in Scotland’,  British Journal of Politics and International Relations, 9,1, 73-89 PDF Paywall Green (it’s also stored by a US University here)

For the broader argument on ‘evolutionary theory, see:

Policy Concepts in 1000 Words: Evolution

Paul Cairney (2013) ‘What is Evolutionary Theory and How Does it Inform Policy Studies?’ Policy and Politics, 41, 2, 279-98

What is ‘Complex Government’ and what can we do about it?

 

 

 

 

 

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The Tobacco ‘Endgame’

The journal Tobacco Control has a section discussing the idea of an endgame. Previously, the focus was on controlling the tobacco market and reducing smoking. Now, the focus is often on eradicating both. So far, there are two main types of paper:

  • Those which propose new, harder, policy instruments – from introducing new regulations on tobacco products (including nicotine content) and the sales practices of the industry, to a ban on the sale of cigarettes altogether or to people born after a particular date.
  • Those which discuss politics and policymaking – including discussions about the level of consensus on the scientific and ethical case for endgame policies. Some papers consider the most-likely organisations to foster an endgame approach, although most are examining the peculiarities of the US.
  • One paper by Myers argues that the World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) remains a key means to ensure global tobacco control: the problem is not a lack of new policy instruments, but the ‘political will’ to implement the ones we have.

This is where our (soon to be submitted) paper comes in. Hadii Mamudu and I aim to draw on the insights from the public policy literature (and interviews with policymakers and advocates across several countries) to (a) demonstrate the importance of this focus on politics and policymaking; and (b) explain in detail how and why that is important.

I won’t post the paper yet (to address concerns by the Journal ) but here is the draft abstract, followed by a draft set of bullet points which will accompany the submission:

The tobacco ‘endgame’ represents a major shift in focus, from controlling the tobacco market and reducing smoking, to eradicating both. Yet, the uneven spread of effective global tobacco control suggests that this outcome is far more likely in some countries than others.  We analyse the implementation of the FCTC to identify this problem, and synthesis the public policy literature to present a solution. The aim is to come as close as possible to the ideal-type of ‘comprehensive tobacco control regimes’, in which countries have policy environments conducive to the introduction of a wide range measures to reduce the demand for, and supply of, tobacco products. This would require the following policy processes in each country: their department of health takes the policy lead (replacing trade and treasury departments); tobacco is ‘framed’ as a pressing public health problem, not an economic good; public health groups are consulted at the expense of tobacco companies; socioeconomic conditions (including the value of tobacco taxation, and public attitudes to tobacco control) are conducive to policy change; and, the scientific evidence on the harmful effects of smoking and secondhand smoking are ‘set in stone’ within governments.

Why the issues discussed are important in terms of controlling tobacco use:

  • It makes a crucial contribution to Tobacco Control’s endgame debate.
  • Too many academic articles recommend policy instruments alone, to solve problems, without considering how effective they will be implemented
  • The policy process is not a ‘black box’. Instead, it is a system or environment that has to be understood in considerable depth – using the wealth of policy sciences literature.
  • The scientific research on tobacco control will not be fully evidence-based if we focus solely on the evidence on smoking related behaviour, or the efficacy of some policy instruments in isolation.
  • Instead, we need to consider the global context and use country comparisons to learn lessons about policy progress.
  • So far, most endgame papers in Tobacco Control have focused on instruments or the politics and policymaking of the US.
  • Only one paper supports the combination of the FCTC and ‘political will’.
  • Our paper supports and goes well beyond that argument. It gives more meaning to the vague idea of ‘political will’, which could relate (for example) to exceptional individual policymakers or organisation at various levels and types of government. It often represents vague criticism of the political process in general without trying to understand how it works.
  • We show that the policy environment, in which governments implement international agreements such as the FCTC (containing a combination of major tobacco control instruments), is just as important as the FCTC itself.
  • We suggest that the effective implementation of the FCTC could take decades – an outcome that may be frustrating, but not should not come as a surprise or necessarily prompt a shift of approach.

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