Tag Archives: Tobacco Control

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

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

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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Action on Sugar: Learning from Tobacco

In many ways, tobacco control has set the agenda for controls in other areas, such as (most notably) alcohol. We can see this by simply comparing recent calls for action on sugar in food with existing curbs on tobacco use, taking out the ones that are not comparable or might seem a step too far (at least for now, warns the IEA and DP). Here are the types of policy instruments for tobacco and I have put an asterisk next to the latest recommendations on food.

I. Regulation (through legislation or voluntary agreements)

  1. Bans or restrictions on advertising and promotion (e.g. to disassociate the product with physical activity).*
  2. Sales to children.
  3. Smoking and eating in public places (second-hand smoke).
  4. Modify and regulate ingredients, such as the levels of tar in cigarettes and the levels of sugar, salt and fat in food.*
  5. Customs enforcement on smuggling and counterfeit products.

II. Finance

  1. Taxation and other levies to discourage consumption of certain products.*
  2. Spending on directed health services, including cessation services.
  3. The reform of economic incentives, including agricultural incentives and tax expenditures on arts and sports sponsorship by companies.*
  4. Litigation against companies (more a US than UK practice).

III. Capacity building

  1. Funding for community development programs and organisations to combat use.

IV. Education

  1. Health warning labels on packaging.*
  2. Health education campaigns.*

V. Learning and information tools

  1. Legislative hearings* and executive reports (US) and reports by the Chief Medical Officer (UK).
  2. Funding scientific research on the harms of products.*

Donley Studlar and I tried to do something more extensive on tobacco alcohol in these tables – tobacco alcohol table 25.7.13 – before taking them out in the last cut of our forthcoming article (draft here Cairney Studlar Public health in the UK March 26 2014). See also: http://blogs.lse.ac.uk/politicsandpolicy/for-those-who-seek-to-strengthen-alcohol-regulation-the-experience-of-tobacco-control-shows-that-comprehensive-policy-change-is-neither-quick-nor-inevitable/

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Journal Article Acceptance(s) After 5 Rejections and 25 months

Update: the title is now less catchy but more accurate. See the italicised bits for the update. I have also added this poster:

hang-in-there-baby

You might have to be a glass-is-half-full kind of person to take something positive from this story of publication success after a long run of failure. After 18 months, 5 rejections, 4 substantial redrafts, 2-3 changes of journal direction, and minus 8000 words, we had it accepted (update: add another 7 months,  and three substantial redrafts and additions, for the 2nd article acceptance).

It began with our submission to World Politics, which is a high status journal, in politics and international relations, with a high rejection rate, so this was a gamble. I thought we had done the double: produced something interesting to say about ‘evolutionary’ policymaking, building on work I began for Understanding Public Policy; and, produced a wealth of new information on global tobacco policy, built on work led by Donley Studlar and Hadii Mamudu, and informing Global Tobacco Control. So, HM and I put both together to produce this paper, submitted 11th September 2012:

World Politics Evolutionary Theory International Agreements 11September2012

It was rejected on the 4th December (not a bad turnaround). The rejection came with substantial reviewer comments – World Politics decision letter – which we used to revise the next version substantially. My impression, from this review, was that the combination of evolutionary theory and the case study was not working. In fact, I may have been pushing us into a position that I advise PhD students and early career researchers to avoid: a paper suggesting a new theoretical angle, reinforced by a single case . In my defence, I wasn’t proposing a new theory. Instead, I was trying to present the approach as a reflection of accumulated knowledge, in both theory and case.

Still, it wasn’t working, so we separated the two elements somewhat. I chopped about 3000 words of theory – something made easier by the fact that I had submitted (February 2012) a separate paper on evolutionary theory to Policy and Politics, which was reviewed (July 2012) and accepted after a minor revise-and-resubmit (23 October) then published early 2013 – ‘What is Evolutionary Theory and How Does it Inform Policy Studies?’ Policy and Politics, 41, 2, 279-98 Paywall Green

We hummed and hawed about policy journals before I made the mistake of sending it to Public Administration and Development, partly because we were focusing on contrasts in implementation based on the simple developed/ developing country distinction, partly because it was interdisciplinary, and partly because its description seemed really close to our topic.

Cairney Mamudu Evolution Tobacco Control PAD submission 5Feb2013

It was rejected without going to review, described by the editor as ‘out of scope’.

So, we sent it, almost immediately (21 Feb 2013), to Governance, which had been HM’s (more sensible) preference. Again, this is a high status political/ policy science journal with a high rejection rate, so we were still confident enough to take the usual gamble.

Anonymous Evolution Tobacco Control Governance submission 21Feb2013

It was rejected on 26th May after substantial review (which seems more critical than the reviewers of World Politics, so we were no further forward) –  governance rejection

We figured that we had to do two things based on the reviews: (1) strip out the discussion of evolutionary theory more and focus on the basic political science concepts (implementation, networks, agendas, etc.), shifting back the focus to the case study and evidence so far (particularly since I had now published an article separately on evolutionary theory); (2) be super-clear on key terms (leading/ laggard; developed/ developing) to anticipate future concerns, and clarify the narrative on the origins and role of the FCTC.

By this time, my University had made available some funds for Open Access, and I was keen to go this route, partly because OA seems good, and partly because I had recently co-authored an article in the OA journal Implementation Science and it was a very positive experience.

We chose Globalization and Health – based at the LSE, interdisciplinary, covering our topic and focus – and submitted on 12th September 2013. It was rejected on 29th October, which is a good turnaround, but the reviews were too brief to be useful – except it is still clear that our attempts to address the developed/ developing distinction are still needling our referee audience.

GH rejection letter GH referee 1 GH referee 2

Our solution was twofold: (1) to check with the editor of the next journal if there would be a problem with our approach, and (2) to get away from the developed/ developing sticking point by presenting an even more nuanced account, taking every opportunity to show that we weren’t providing naïve caricatures, and going super-conceptual to describe an ideal-type of a leading implementing country rather than identifying ‘leaders’ and ‘laggards’.

I emailed the editors of the Journal of Public Health Policy in November and got a good assurance on the developed/ developing point. The only problem is that the word limit is 4000, which is about one-third of the length of our original paper. Still, we revised the paper again.

By then, HM reckoned that Tobacco Control was a better fit, since they had begun to publish a series of papers on the ‘endgame’. We submitted there on the 20th December.

TCJ-Endgame_CoverLetter-14Dec2013 2 Cairney Mamudu Checklist cover letter 3 Cairney-Mamudu_22Dec2013

They rejected it on the 8th January 2014 without sending it to review TC rejection

We sent it to the JPHP on the 10th January – 1 CAirney Mamuducover letter JPHP 10JAn14 2 CAirney Mamudu Submitted article JPHP 10JAn14

We got a revise and resubmit on the 17th February – a very decent turnaround indeed. We got the classic binary response: one thought it was great, and one thought it was mince – JPHP reviews 17.2.14

We resubmitted on March 13 – 1 cover and rebuttal letter 2 resubmitted JPHP    – and got the thumbs up by the 27th.

Update, November 2014. We submitted a much better paper on the same theme (more developed theoretical argument, more data, a better refined argument) to Public Administration (special issue on global public policy) in June. After two resubmissions (and, unusually, a referral to a member of the editorial board – to deal with comments made by the third reviewer), we had it accepted in November.

So what did we learn?

    1. It is natural to blame journals, editors and reviewers for these long, drawn out processes – but I need to take some responsibility for the journal choices and the quality of submissions.
    2. Even a rejection can give you useful material for a redraft, as long as it actually goes to review.
    3. It is worth persevering. This is a very unusual case of 5 rejections, but it seem fairly normal to get 1 or 2 before success. For a while, I went on a good run of acceptances-after-revision, then a run of acceptances after rejection. I have almost always published each paper by the end.
    4. I think the article is, in many ways, a far better paper than when it began – but it also changed so much that we reckon we can go back and submit some of the chopped material (the new data) elsewhere.
    5. Final lesson – you need a thick skin for this process, particularly when you get one or two cranky anonymous reviewers, and particularly when you go interdisciplinary and invite comment from people who often don’t respect your discipline.
    6. Final, final, updated lesson: don’t lose your confidence and settle for a second-best result. Our first acceptance was for an article that stripped away a lot of what was good in the original idea (partly to meet the 4000 word limit), and it was rewritten for a public health audience in a way that I don’t entirely like. The Public Administration article (9000 words) is the one I’ll send to people and be proud of. It was accepted more than two years after we first made the mistake to send it to a different journal.

 

 

 

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