Tag Archives: Public health

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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The politics of implementing evidence-based policies

This post by me and Kathryn Oliver appeared in the Guardian political science blog on 27.4.16: If scientists want to influence policymaking, they need to understand it . It builds on this discussion of ‘evidence based best practice’ in Evidence and Policy. There is further reading at the end of the post.

Three things to remember when you are trying to close the ‘evidence-policy gap’

Last week, a new major report on The Science of Using Science: Researching the Use of Research Evidence in Decision-Making suggested that there is very limited evidence of ‘what works’ to turn scientific evidence into policy. There are many publications out there on how to influence policy, but few are proven to work.

This is because scientists think about how to produce the best possible evidence rather than how different policymakers use evidence differently in complex policymaking systems (what the report describes as the ‘capability, motivation, and opportunity’ to use evidence). For example, scientists identify, from their perspective, a cultural gap between them and policymakers. This story tells us that we need to overcome differences in the languages used to communicate findings, the timescales to produce recommendations, and the incentives to engage.

This scientist perspective tends to assume that there is one arena in which policymakers and scientists might engage. Yet, the action takes place in many venues at many levels involving many types of policymaker. So, if we view the process from many different perspectives we see new ways in which to understand the use of evidence.

Examples from the delivery of health and social care interventions show us why we need to understand policymaker perspectives. We identify three main issues to bear in mind.

First, we must choose what counts as ‘the evidence’. In some academic disciplines there is a strong belief that some kinds of evidence are better than others: the best evidence is gathered using randomised control trials and accumulated in systematic reviews. In others, these ideas have limited appeal or are rejected outright, in favour of (say) practitioner experience and service user-based feedback as the knowledge on which to base policies. Most importantly, policymakers may not care about these debates; they tend to beg, borrow, or steal information from readily available sources.

Second, we must choose the lengths to which we are prepared to go ensure that scientific evidence is the primary influence on policy delivery. When we open up the ‘black box’ of policymaking we find a tendency of central governments to juggle many models of government – sometimes directing policy from the centre but often delegating delivery to public, third, and private sector bodies. Those bodies can retain some degree of autonomy during service delivery, often based on governance principles such as ‘localism’ and the need to include service users in the design of public services.

This presents a major dilemma for scientists because policy solutions based on RCTs are likely to come with conditions that limit local discretion. For example, a condition of the UK government’s license of the ‘family nurse partnership’ is that there is ‘fidelity’ to the model, to ensure the correct ‘dosage’ and that an RCT can establish its effect. It contrasts with approaches that focus on governance principles, such as ‘my home life’, in which evidence – as practitioner stories – may or may not be used by new audiences. Policymakers may not care about the profound differences underpinning these approaches, preferring to use a variety of models in different settings rather than use scientific principles to choose between them.

Third, scientists must recognise that these choices are not ours to make. We have our own ideas about the balance between maintaining evidential hierarchies and governance principles, but have no ability to impose these choices on policymakers.

This point has profound consequences for the ways in which we engage in strategies to create impact. A research design to combine scientific evidence and governance seems like a good idea that few pragmatic scientists would oppose. However, this decision does not come close to settling the matter because these compromises look very different when designed by scientists or policymakers.

Take for example the case of ‘improvement science’ in which local practitioners are trained to use evidence to experiment with local pilots and learn and adapt to their experiences. Improvement science-inspired approaches have become very common in health sciences, but in many examples the research agenda is set by research leads and it focuses on how to optimise delivery of evidence-based practice.

In contrast, models such as the Early Years Collaborative reverse this emphasis, using scholarship as one of many sources of information (based partly on scepticism about the practical value of RCTs) and focusing primarily on the assets of practitioners and service users.

Consequently, improvement science appears to offer pragmatic solutions to the gap between divergent approaches, but only because they mean different things to different people. Its adoption is only one step towards negotiating the trade-offs between RCT-driven and story-telling approaches.

These examples help explain why we know so little about how to influence policy. They take us beyond the bland statement – there is a gap between evidence and policy – trotted out whenever scientists try and maximise their own impact. The alternative is to try to understand the policy process, and the likely demand for and uptake of evidence, before working out how to produce evidence that would fit into the process. This different mind-set requires a far more sophisticated knowledge of the policy process than we see in most studies of the evidence-policy gap.  Before trying to influence policymaking, we should try to understand it.

Further reading

The initial further reading uses this table to explore three ways in which policymakers, scientists, and other groups have tried to resolve the problems we discuss:

Table 1 Three ideal types EBBP

  1. This academic journal article (in Evidence and Policy) highlights the dilemmas faced by policymakers when they have to make two choices at once, to decide: (1) what is the best evidence, and (2) how strongly they should insist that local policymakers use it. It uses the case study of the ‘Scottish Approach’ to show that it often seems to favour one approach (‘approach 3’) but actually maintains three approaches. What interests me is the extent to which each approach contradicts the other. We might then consider the cause: is it an explicit decision to ‘let a thousand flowers bloom’ or an unintended outcome of complex government?
  2. I explore some of the scientific  issues in more depth in posts which explore: the political significance of the family nurse partnership (as a symbol of the value of randomised control trials in government), and the assumptions we make about levels of control in the use of RCTs in policy.
  3. For local governments, I outline three ways to gather and use evidence of best practice (for example, on interventions to support prevention policy).
  4. For students and fans of policy theory, I show the links between the use of evidence and policy transfer

You can also explore these links to discussions of EBPM, policy theory, and specific policy fields such as prevention

  1. My academic articles on these topics
  2. The Politics of Evidence Based Policymaking
  3. Key policy theories and concepts in 1000 words
  4. Prevention policy

 

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The politics of evidence-based best practice: 4 messages

Well, it’s really a set of messages, geared towards slightly different audiences, and summed up by this table:

Table 1 Three ideal types EBBP.JPG

  1. This academic journal article (in Evidence and Policy) highlights the dilemmas faced by policymakers when they have to make two choices at once, to decide: (1) what is the best evidence, and (2) how strongly they should insist that local policymakers use it. It uses the case study of the ‘Scottish Approach’ to show that it often seems to favour one approach (‘approach 3’) but actually maintains three approaches. What interests me is the extent to which each approach contradicts the other. We might then consider the cause: is it an explicit decision to ‘let a thousand flowers bloom’ or an unintended outcome of complex government?
  2. I explore some of the scientific  issues in more depth in posts which explore: the political significance of the family nurse partnership (as a symbol of the value of randomised control trials in government), and the assumptions we make about levels of control in the use of RCTs in policy.
  3. For local governments, I outline three ways to gather and use evidence of best practice (for example, on interventions to support prevention policy).
  4. For students and fans of policy theory, I show the links between the use of evidence and policy transfer.

Further reading (links):

My academic articles on these topics

The Politics of Evidence Based Policymaking

Key policy theories and concepts in 1000 words

Prevention policy

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Case studies: healthcare, public health, mental health #POLU9SP

This is the second of three posts which use case studies of cross-cutting and specific policy areas to add more depth to our discussion of Scottish politics and policymaking.

Most aspects of health policy have been devolved since 1999, and many were devolved before 1999, so we can generate a relatively long term picture of policy change/ divergence in three key areas: healthcare, mental health, and public health. We can then revisit the idea of prevention and inequalities raised in the first lecture.

Healthcare

The NHS has always been a little bit different in Scotland, which enjoyed administrative devolution – through the Scottish Office (a UK Government Department) – before 1999 and maintained its own links with professional groups.

Scotland has traditionally trained a disproportionate number of UK doctors and maintained an unusually high presence of Royal Colleges. This greater medical presence boosted the Scottish Office’s policymaking image as ‘professionalised’, or more likely to pursue policies favoured by the medical profession than the UK’s Department of Health. For example, it appeared to be less supportive of reforms based on the ‘marketisation’ of the NHS.

Devolution turbo boosted this sense of Scottish policy difference (see the Greer and Jarman discussion).

For example, while the UK Labour Government furthered the ‘internal market’ established by its Conservative predecessors, the Labour-led Scottish Government seemed to dismantle it (for example, there are no Foundation hospitals). It also bought (and effectively renationalised) a private hospital, which had a symbolic importance way above its practical effect.

Since 2007, the SNP-led Scottish Government – often supported publicly by UK-wide groups such as the British Medical Association (and nursing and allied health professions) – has gone big on this difference between Scottish and UK Government policies, criticising the marketization of the NHS in England and expressing, at every opportunity, the desire to maintain the sort of NHS portrayed by Danny Boyle at the Olympics opening ceremony.

This broad approach is generally supported, at least implicitly, by the important political parties in Scotland (the SNP is competing with a centre-left Labour Party and the Conservatives are less important). It is also supported by a medical profession and a public that, in practice, tends to be more committed to the NHS (in other words, opinion polls may not always show a stark difference in attitudes, but there is not the same fear in Scotland, as in the South-East of England, that doctors and patients might defect to the private sector if the NHS is not up to scratch).

Public health

Scotland won the race to ban smoking in public places and is currently trying to introduce a minimum unit price for alcohol. It has also placed particular emphasis on the wider determinants of health and made the right noises about the balance between public health and acute care. However, there are also major similarities in Scottish and UK Government approaches. For example, the UK tops the European league table on comprehensive tobacco control (and England/ Wales beat Scotland to ban smoking in cars with children).

Mental health

To some extent, early Scottish Governments developed an international reputation for innovation in some areas relating to wellbeing. It also reformed mental health and capacity legislation in a relatively quick and smooth way – at least compared to the UK Labour Government, which had a major stand-off with virtually all mental health advocacy groups on psychiatric-based reforms. Part of the difference relates to the size of Scotland and its government’s responsibilities which can produce a distinctive policy style; it often has the ability to coordinate cross-cutting policy, in consultation with stakeholders, in a more personal way. However, this is a field in which there tend to be often-similar policies beyond the Sun-style headlines.

The bigger picture of continuity: a tax funded service

These Scottish-UK differences should be seen in the context of a shared history and some major similarities. Both NHS systems are primarily tax-funded and free at the point of use, with the exception of some charges in England (which should not be exaggerated – for example, 89% of prescriptions in England are tax-funded). Both governments have sought to assure the public in similar ways by, for example, maintaining high profile targets on waiting times. Both systems face similar organisational pressures, such as the balance between a public demand for local hospitals and medical demand for centralised services. Both governments face similar demographic changes which put pressure on services. Both have similarly healthy (or unhealthy) populations.

The bigger picture of prevention and health inequality

Although the Scottish Government pursues an agenda on prevention to reduce service demand and health inequalities, many other policies based on the idea of universal provision have the potential to exacerbate inequalities.

For example, a real rise in spending (cash spending adjusted with the GDP deflator) on health policy of 68% from 2000-11 did not have a major effect on health inequalities (Cairney and McGarvey, 2013: 229). Instead, Scottish Governments tended to use the money in areas such as acute care to, for example, maintain high profile waiting list (non-emergency operations) and waiting times (A&E) targets which did not have a health inequalities component (Cairney, 2011: 177-9). It has also phased out several charges, such on prescriptions and eye tests, which increase spending without decreasing inequalities (particularly since the lowest paid already qualified for exemptions for charges).

It has pursued strongly a public health strategy geared, in part, towards reducing health inequalities, but with the same tendency as in the UK for healthcare to come first. This process includes interesting overlaps in aims and outcomes, such as in tobacco control where smoking is addressed strongly partly because it represents the single biggest element of health inequalities, but most initiatives do not necessarily reduce inequalities in smoking.

Further Reading

I discuss these issues in more depth in Scottish Politics and The Scottish Political System Since Devolution. See also this draft chapter on prevention and health policy by the Scottish and UK Governments

 

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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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