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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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Filed under alcohol, Public health, public policy, tobacco, tobacco policy, UK politics and policy

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

The United Kingdom now has one of the most comprehensive tobacco control policies in the world, a far cry from its status two decades ago. Some influential public health voices have called for a similar campaign against alcohol consumption. But is the comparison appropriate? We identify the factors which were important in the relatively successful campaign for tobacco control, then analyse the obstacles and opportunities facing the movement for more stringent alcohol control. Alcohol policy today bears a striking resemblance to tobacco policy pre-1990s, when the UK started on its path to becoming a major regulatory state in the world. Can alcohol policy be changed in a similar way?

Paper here  Cairney Studlar 2014 WMHP Alcohol and Tobacco Policy UK

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

See also: http://blogs.lse.ac.uk/impactofsocialsciences/2013/07/16/evidence-matters-tobacco-and-alcohol-comparison/

*We submitted the paper to a US journal, where this framing is more normal. The idea of a public health crusade is also in good currency in some libertarian circles.

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Filed under agenda setting, alcohol, alcohol policy, Evidence Based Policymaking (EBPM), Public health, tobacco, tobacco policy, UK politics and policy

Alcohol: the Harmful versus Healthy Debate

I predict a lot of debate and attention to the idea that alcohol consumption is healthy or harmful. A key strategy for public health groups and other advocates of further alcohol controls (such as a minimum unit price of alcohol) is to reframe the debate – by challenging the idea that alcohol can be healthy, in particular circumstances, if consumed in small amounts. A key strategy for the alcohol industry is to maintain that image so that they can argue that alcohol policy should be targeted at problem drinkers only. One is a public health argument calling for general policy measures that influence the drinking habits of the population (e.g. raise prices, ban promotion). The other is an individualised argument calling for specific measures that deal with particular people (e.g. provide NHS services for alcoholism; change police powers to deal with anti-social behaviour). So, the *way we understand the evidence* is key battle ground in the policy debate. That is why you will find public health groups so bothered by the fact that the industry takes such an important part in the production, dissemination and interpretation of the evidence within government and when communicating with the public (e.g. drinkaware.org is funded by the industry).

The obvious contrast, at least in the UK, is between alcohol and tobacco. In the latter, in the not-too-distant past, tobacco companies had similar amounts of joy in government and public circles: funding scientific research; arguing that the link between smoking (and then passive smoking) and ill health was not proven; and portraying the issue as one of individual choice based on their thoughts on the evidence and how they might way it up against their enjoyment of smoking. Key strides were made in tobacco control when the evidence on harm (from smoking and passive smoking) were ‘set in stone’ within government and stated unequivocally to the public. A good example is in health education before and after tobacco company influence. In the heyday of smoking (when men were men), the public health advice was overshadowed by tobacco advertising. It was also more likely to be harm reduction in nature – e.g. smoke pipes rather than cigarettes (not too long after companies introduced healthful (not really) filtertips and moved from high to low tar). Then, the health advice changed markedly to reflect a ‘no safe level’ message (as in the health advice suggesting that a move from high to low tar was like jumping from the 38th floor of a building rather than the 39th).

Now, in my day, as an undergraduate, we might try to interpret that sort of story in terms of early insights on Power by people like Bachrach and Baratz. Power is not simply about visible conflicts in which one group wins and another loses (such as in a policy debate in government). Rather, groups may exercise power to reinforce social attitudes (perhaps to make sure that the debate does not get that far). If the weight of public opinion is against government action, maybe governments will not intervene. In this case, if the vast majority of people think that moderate alcohol consumption is healthy (or not harmful), they may not support control measures that affect the whole population. In fact, it is a measure of public health group success that it even *occurs* to us to consider the issue. Still, a key part of the minimum-unit-price debate is that it punishes responsible drinkers as much as problem drinkers. This will not be such a powerful argument if the vast majority of the public begins to believe that we are *all* problem drinkers (well, apart from me – I don’t touch the stuff).

See also: http://blogs.lse.ac.uk/politicsandpolicy/archives/34735

‘Alcohol’s evaporating health benefits’ http://linkis.com/www.bmj.com/content/kpLcG

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Filed under agenda setting, alcohol, alcohol policy, public policy, tobacco, tobacco policy

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

The obvious answer is that drinking is less bad for you than smoking. Or, if you are the optimistic sort, drinking is really, really, really, really, really good for you – mm, mm, delicious and nutritious. And it’s cool. And it’s sexy and it makes you sexy. Especially when you are pissed.

The non-obvious answer is that, although the same sort of public health evidence has been produced to suggest that: (a) both smoking and drinking are unhealthy; and, (b) both should be controlled using similar instruments – the alcohol-is-unhealthy evidence is less accepted in government and alcohol control policies are a harder sell (for now). Alcohol can still be advertised, there is less tax on booze and the alcohol industry has a regular say in the interpretation of the evidence (and what we should do about it).
The aim of this ICPP paper (link) is to explain the difference between policy choices in tobacco and alcohol. It says: here is what would have to happen for alcohol control to mimic tobacco control (I do the same in a comparison of tobacco controls in different countries here). We can break the policy process down into five key factors:
1.     Institutional change. Government departments, and other organisations focused on health policy, would take the main responsibility for alcohol control, largely replacing departments focused on finance, trade, industry, tourism and employment (and crime).
2.      Paying attention to, and ‘framing’ the problem. The government would no longer view alcohol primarily as a product with economic value, central to the ‘night time economy’.  It would be viewed primarily as a public health problem; a set of behaviours and outcomes to be challenged.  This happened with tobacco, but it is trickier in alcohol because the government may only be worried about aspects of alcohol consumption (such as the binge drinking and anti-social behaviour of certain individuals) rather than the broader notion of public health.
3.      The balance of power between participants.  The department of health would consult public health and medical groups at the expense of groups representing the alcohol industry. This is central to the type of evidence it gathers, the interpretation of the evidence, and the advice it receives.
4.      The socioeconomic context.  The economic benefit of alcohol consumption would fall (or, the tax revenue would become less important to the Treasury), the number of drinkers would fall and opposition to alcohol control would decline (although it already seems fairly low).
5.      The role of beliefs and knowledge.  The scientific evidence linking alcohol consumption to ill health would have to be accepted and ‘set in stone’ within government circles.  The most effective policies to reduce alcohol consumption would also be increasingly adopted and transferred across countries.
Change in these factors would be mutually reinforcing.  For example, an increased acceptance of the scientific evidence helps shift the way that governments ‘frame’ or understand the alcohol policy problem.  The framing of alcohol as a health problem allows health departments to take the policy lead.  Alcohol control and alcohol use go hand in hand: a decrease in drinking rates reduces the barriers to alcohol control; more alcohol control means fewer drinkers (or less drinking).
It is tempting to think that this sort of process is more likely under Labour and less likely under the Conservatives – and there is some evidence to back up this argument. However, the point of the paper is that these long term processes develop during the terms of both parties. Major policy change, of the level we have witnessed in tobacco (but not as much in alcohol), takes several decades. Indeed, you can be suitably impressed or depressed with my hunch that alcohol control is at least a decade (if not two or more) behind tobacco.

See also: http://paulcairney.blogspot.co.uk/2013/06/alcohol-harmful-versus-healthy-debate.html
Compare with: http://velvetgloveironfist.blogspot.co.uk/2013/07/the-real-reason-for-public-smoking-bans.html and http://dickpuddlecote.blogspot.co.uk/2013/07/an-lse-guide-on-how-to-denormalise.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+DickPuddlecote+(Dick+Puddlecote)

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Filed under alcohol, alcohol policy, Evidence Based Policymaking (EBPM), public policy, tobacco, tobacco policy, UK politics and policy, Uncategorized