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

Politics 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.

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 …

…but also

• …the space in which local authorities can fund the most ‘evidence-based’ interventions according to the Early Intervention Foundation.

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:

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.

Writing an essay on politics, policymaking, and policy change

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

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

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

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

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

Choosing a format: the initial advice

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

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

Choosing a format: the cautionary advice

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

Choosing a topic: the ‘joined up’ advice

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

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

Some examples from my pet subject

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

What is modern UK tobacco policy?

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

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

How much has policy changed since the 1980s?

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

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

Why has it changed?

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

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

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

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

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

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

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

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

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

What is Policy?

Compare with What is the Policy Process? and What is public policy and why does it matter?

The first thing we do when studying public policy is to try to define it – as, for example, the sum total of government action, from signals of intent to the final outcomes. This sort of definition produces more questions:

• Does ‘government action’ include what policymakers say they will do as well as what they actually do? An unfulfilled promise may not always seem like policy.
• Does it include the effects of a decision as well as the decision itself? A policy outcome may not resemble the initial policy aims.
• What is ‘the government’ and does it include elected and unelected policymakers? Many individuals, groups and organisations influence policy and help carry it out.
• Does public policy include what policymakers do not do. Policy is about power, which is often exercised to keep important issues off the public, media and government agenda.

The second thing we do is point to the vast scale of government, which is too big to be understood without some simplifying concepts and theories. It is also too big to be managed. We soon learn that the vast majority of policymaking takes place in the absence of meaningful public attention. The ‘public’ simply does not have the time to pay attention to government. Even when it pays attention to some issues, the debate is simplified and does not give a good account of the complicated nature of policy problems.

We also learn that government is too big to be managed by elected policymakers. Instead, they divide government into manageable units and devolve almost all decisions to bureaucrats and organisations (including ‘street level’).  They are responsible for government, but they simply do not have the time to pay attention to anything but a tiny proportion.

So, a big part of public policy is about what happens when neither the public nor elected policymakers have the ability to pay attention to what goes on in their name. That’s what makes it seem so messed up and so interesting at the same time.

It’s also what makes policy studies look so weird. We often reject a focus on high-profile elected policymakers, because we know that the action takes place elsewhere. We often focus on the day-to-day practices of organisations far removed from the ‘top’ or the ‘centre’. We ‘zoom in’ and ‘zoom out’ to gain several perspectives on the same thing. We spend a lot of time gnashing our teeth about how you can identify and measure policy change (still, no-one has cracked this one) and compare it with the past and the experience of other countries. We try to come up with ways to demonstrate that inaction is often more significant than action. When you ask us a question, your eyes will glaze over while we try to explain, ‘well, that’s really 12 questions’. We come up with wacky names to describe policymaking and bristle if you call it ‘jargon’. It’s because policymaking is complicated and it takes skill, and some useful concepts, to make it look simple.

To read more, see: Policy Concepts in 1000 words

(to store the podcast, right click and save this link)

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’

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

3. 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

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?

 

 

 

 

 

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/

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:

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 11^th September 2012:

World Politics Evolutionary Theory International Agreements 11September2012

It was rejected on the 4^th 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 26^th 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 12^th September 2013. It was rejected on 29^th 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 20^th December.

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

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

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

We got a revise and resubmit on the 17^th 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 27^th.

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.

 

 

 

Policy Concepts in 1000 Words: Policy change and measurement

(podcast download)

The first thing we learn when we study public policy is that no-one is quite sure how to define it. Instead, introductory texts focus on our inability to provide something definitive. That is OK if we want to pretend to be relaxed about life’s complexities, but not if we want to measure policy change in a reasonably precise way. How can we measure change in something if we don’t know what it is?

A partial solution is to identify and measure types of public policy. For example we might treat policy as the collection of a large number of policy instruments or decisions, including:

1. Public expenditure. This includes deciding how to tax, how much money to raise, on which policy areas (crime, health, education) to spend and the balance between current (e.g. the wages of doctors) and capital (building a new hospital) spending.
2. Economic penalties, such as taxation on the sale of certain products, or charges to use services.
3. Economic incentives, such as subsidies to farmers or tax expenditure on certain spending (giving to charity, buying services such as health insurance).
4. Linking government-controlled benefits to behaviour (e.g. seeking work to qualify for unemployment benefits) or a means test.
5. The use of formal regulations or legislation to control behaviour.
6. Voluntary regulations, such as agreements between governments and other actors such as unions and business.
7. Linking the provision of public services to behaviour (e.g. restricting the ability of smokers to foster children).
8. Legal penalties, such as when the courts approve restrictions on, or economic sanctions against, organizations.
9. Public education and advertising to highlight the risks to certain behaviours.
10. Providing services and resources to help change behaviour.
11. Providing resources to tackle illegal behaviour.
12. Funding organizations to influence public, media and government attitudes.
13. Funding scientific research or advisory committee work.
14. Organizational change, such as the establishment of a new unit within a government department or a reform of local government structures.
15. Providing services directly or via non-governmental organizations.
16. Providing a single service or setting up quasi-markets.

I say ‘partial solution’ because this approach throws up a major practical problem: we do not have the ability to track and characterise all of these instruments in a satisfactory or holistic way. Rather, we have to make choices about what information to use (and, by extension, what to ignore) to build up a partial, biased, picture of what is going on. Here are some of the practical problems we face:

Depth versus breadth. Should I focus on one policy instrument or all of them (or some combination)? Should I focus on a single key event or a picture of change over decades? Should I focus on the outputs of one policymaking organization or them all, or try to track the outcomes of the system as a whole? In each case there is a major trade-off: if we ‘zoom in’ we might miss broad or long term trends; if we ‘zoom out’ we might miss important details.

Our empirical and normative expectations. When we identify policy change we link it, explicitly or implicitly, to a yardstick based on how much we expect it to change (based on, for example, the abilities of people to initiate and block change) and how much we think policy should change under the circumstances, given the size of problem or the level of public attention. Our normative expectations are difficult to separate from the empirical. Think of cases such as air pollution, environmental policy, tobacco, alcohol and drugs control, violent crime, poverty, and inequality. In each case, we have expectations about what should happen based on how important we believe the problem to be – and may often identify minor or moderate change, based on that perception, rather than compared with (say) change in other areas.

Differing perspectives. Policy change looks very different from the ‘top’ or the ‘bottom’. For example, a focus on policy choices by central governments may exaggerate change compared to long term outcomes at the ‘street level’. Indeed, it is tempting to focus on rapid, exciting changes at the top, without thinking through their long term consequences. Or, we may find reformers at the top, frustrated with a lack of progress, compared with local actors frustrated with the effects of the rapid pace of change on their organisations.

Motivation. In each case, we have to think about why a policy decision was made: what problem was it designed to solve? For example, a tax or economic sanction can be used to influence behaviour or simply to raise revenue (think, for example, of ‘sin’ taxes). Policymakers can introduce measures to satisfy a particular interest or constituency, ensure a boost to their popularity or fulfil a long-term commitment based on fundamental beliefs. The distinction is crucial if the long term political weight behind a measure determines its success.

Statistical comparisons. When we consider the use of economic measures, we need an appropriate context in which to consider its significance. We may describe spending on an issue as a proportion of GDP, a proportion of the government budget, a proportion of the policy area’s budget, and in terms of change from last year or over many years. In some cases the amount of money spent or raised by government could be compared with that spent by industry, such as when a health education budget is dwarfed by tobacco/ alcohol advertising, or a huge company receives a small fine for environmental or competition law breaches.

Contradictions. Policy as a whole may seem inconsistent, either within a single field (e.g. some governments control tobacco use but also subsidise leaf growing and encourage trade) or across government (e.g. school expulsion policies may exacerbate youth crime).

Given these problems of inevitable bias, I suggest (at the end of this post, and on p30 of the book) that we consider the extent to which our findings can be interpreted in different, and equally plausible, ways.

Everything would be shite in an independent Scotland

Adversarial politics is annoying, and people are bastards, but there is something particularly stupid about a debate that produces people gloating about how shite things would be in an independent Scotland. We might normally expect some critical analysis about stories coming from vested interests, but not if there is a line to maintain. Today’s example comes from the Daily Mail (which specialises in bile and breasts) and Financial Times (which, today, is held up as a provider of the truth carved in stone): supermarket prices will go up in an independent Scotland. Fuel and production costs will push up food costs (kept artificially low, and spread across the UK, by supermarkets just now) and Scottish Government public health policy will keep or push up the cost of tobacco and alcohol. So what might a more critical analysis of this news produce?

1. In almost any other case, the story would be about multinational companies protecting their profits at the expense of the consumer. As with energy prices, this would normally feed into the debate about the cost of living. Yet, in this case, one side of the independence debate is forming a coalition of convenience with those companies.
2. We should not necessarily see the food/ booze & fags argument as separate. The supermarkets have form here, signalling to the consumer that they don’t like restrictions on their trade because they would otherwise make decent profits on cigarettes and alcohol (Sainsbury has even produced a leaflet blaming the Scottish Government for a restriction in sales), and prepared to fight the Scottish Government to protect it. In this case, we should not be surprised that some of it spills over to the independence debate.
3. Prices differ in different parts of the country anyway. It is felt particularly in rural stores which effectively keep price differences by offering only a selected range of (more expensive) products in smaller stores. Your shopping will likely be more expensive in the smaller store in Montrose than in the megasupermarket in Dundee.
4. There is a big difference between some senior staff in supermarkets giving non-quoted scoops in the papers, or named people giving vague comments, and named chief executives actually speaking out in public with substance and subjecting these arguments to critical analysis.

Of course, this is grist to the mill for people who claim that the Yes campaign is ridiculously positive, with no room for anything going wrong. But it usually ends up with people appearing to gloat that everything would be that bit shiter in an independent Scotland.

Update 1: by the end of the day, this (oh dear) might be the story instead

Wouldn't it be great if @Tesco @Sainsburys @Morrisons @Asda just left Scotland after Yes vote http://t.co/zNc4X2fQE9 #IndyRef #PersonalView

— Stan Blackley (@stanblackley) December 9, 2013

compare with the more sensible:

.@murdo_fraser Except supermarkets said no such thing: http://t.co/d98tlmVICB And energy experts said exact opposite! http://t.co/ioFtChI5O5

— Kevin Pringle (@KevinJPringle) December 9, 2013

https://twitter.com/KevinJPringle/status/410135761728847872

Update 2: other coverage is available (I’ve just clicked on any ‘related content’ on my wordpress thing)

Update 3: one of the big bones of contention for supermarkets has been resolved, which is presumably enough for them to stop intervening in the #indyref http://www.bbc.co.uk/news/uk-scotland-scotland-business-25676222

Related articles

• Food prices in an independent Scotland (bbc.co.uk)
• Independent Scotland could pay more for food, supermarkets warn (telegraph.co.uk)
• Food price rise alert for Scotland (bbc.co.uk)
• Independent scots to pay more for food (economicvoice.com)

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 38^th floor of a building rather than the 39^th).

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

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)

Global Tobacco Control

I co-authored a book called Global Tobacco Control: Power, Policy, Governance and Transfer (Palgrave, 2012) with Donley Studlar and Hadii Mamudu. It raises two key questions: Why is there often such a wide gap between the size of the tobacco policy problem and the government response? Why, if the tobacco problem is the same across the globe, does policy vary so markedly across political systems?

It is hardback only, which means that it costs £57.50 to buy a physical copy. Or, it is a snip at £38 if you only want to own the words). Still, the chances are that you won’t own a copy and only libraries will stock it (perhaps reinforcing a not very good academic mantra: books are to be written, not read). Instead, you can read the introduction for free here or have it read to you in an annoying monotone here. This blog provides a summary of the whole argument.

The starting point for the study is to identify the size of the problem. For example, smoking represents the number one preventable cause of death and disease in the world. There are 1.35 billion smokers in the world, smoking is still rising in many countries, and it contributes to one in ten deaths worldwide (over six million per year and rising). The book discusses various ways in which we can express these figures, including breaking them down according to gender and comparing so called ‘developed’ and ‘developing’ countries (and discussing the ‘Tobacco Epidemic Model’ in that context – to follow up this point, see Thun et al’s revision) . The latter distinction is highly problematic (some prefer, for example, high-income countries, HICs, and low- and medium-income countries, LMICs) but also quite useful for our purposes (the United Nations Statistics Division lists developed countries as the US, Canada, Japan, New Zealand, Australia and certain (generally Western, not ‘transitional’ Central and Eastern) European countries). Indeed, the well-discussed ‘tobacco epidemic model’ serves partly to describe the smoking equivalent of a ticking time bomb in many ‘developing’ countries.

Our aim is not to complain that governments are not doing enough to address this problem, or to claim that many government actors are in cahoots with tobacco companies to minimise tobacco regulation – largely because the public health literature (and sites such as the Legal Tobacco Documents Library) does a good job of that already. Further, we do not want to get sued and this paragraph is making me nervous enough already (I kid you not – I don’t even want to give the potentially-slanderous impression that tobacco companies are excessively litigious).

Instead, the study seeks to explain why different governments have responded to this problem so differently. Some countries – like Australia, Canada, Finland, Norway, Sweden, New Zealand, the UK and almost the US (it has more limited controls but, generally, played a huge part in the international tobacco control effort) – now have ‘comprehensive’ tobacco control, which means that they combine a large number of mutually-reinforcing policy instruments designed to reduce smoking in the population (see the WHO ‘MPOWER’ report which identifies six key tobacco control measures: 1) ‘monitor tobacco use and prevention policies’; 2) ‘protect people from tobacco smoke’; 3) ‘offer help to quit tobacco’; 4) ‘warn about the dangers of tobacco’; 5) ‘enforce bans on tobacco adverting, promotion and sponsorship’, and 6) ‘raise taxes on tobacco’). Others do relatively little to address the problem. For example, Germany and Japan are often described as ‘laggard’ developing countries while most developing countries (with exceptions such as Brazil, Singapore, Thailand and Uruguay) have relatively limited tobacco controls.

We also want to know why tobacco control in many countries is now so comprehensive when it was minimal until the 1980s. Many countries which now have comprehensive tobacco control regimes did very little to regulate tobacco until the 1980s. In other words, the gap between the initial identification of smoking (and then passive smoking) related ill health and the initiation of a major policy response was, in most cases, 20-30 years, followed by gradual policy change often over a similar period. The book identifies a history of minimal tobacco control, linked to the power of the tobacco industry (careful now), then charts the extent to which governments, aided by public health advocates, have regulated tobacco domestically and internationally in the modern era.

We explain ‘comprehensive’ change in ‘leading developed’ countries with reference to five key factors:

1. Institutional Change. Government departments, and other organisations focused on health policy, have taken the main responsibility for tobacco control, largely replacing departments focused on finance, agriculture, trade, industry and employment.

2. The Problem Is ‘Framed’ Differently. Tobacco was once viewed primarily as a product with economic value, and tobacco growing and manufacturing was often subsidised or encouraged. Now, it is largely viewed as a public health problem; an epidemic to be eradicated aggressively (or, at least, a problem to be minimised).

3. The Balance Of Power Has Shifted Between Participants. The tobacco industry was an ally of government for decades before and after WWII. When policy was coordinated by finance and other departments, tobacco companies were the most consulted. Now, public health or anti-tobacco groups are more likely to be consulted and tobacco companies are often deliberately excluded.

4. The Socioeconomic Context Has Changed Markedly. The economic benefit of tobacco production and consumption has fallen (for example, tax revenue is less important to finance departments once protective of the industry) and the number of smokers and opposition to tobacco control has declined.

5. The Role Of Beliefs And Knowledge. The production and dissemination of the scientific evidence linking smoking (and now passive smoking) to ill health has been accepted within most government circles. The most effective policies to reduce smoking are increasingly adopted and transferred across countries.

Change in these factors has been mutually reinforcing. For example, increased acceptance of the scientific evidence has helped shift the way that governments understand the tobacco problem. The framing of tobacco as a health problem allows health departments to take the policy lead. Tobacco control and smoking prevalence go hand in hand: a decrease in smoking rates reduces the barriers to tobacco control; more tobacco control means fewer smokers.

We explain the lack of policy change in other countries with reference to the same factors:

1. Health departments are often key players, but their voices are often drowned out by other departments, such as agriculture, finance and trade.

2. Tobacco policy arises on the policy agenda rarely and, when it does, the public health frame competes with attempts to frame tobacco as an economic good.

3. Tobacco companies are powerful and the capacity of anti-tobacco groups is often low.

4. Tobacco growing and manufacturing is an important source of jobs, exports and revenue and smoking prevalence is rising.

5. The medical-scientific knowledge has had less of an effect on the policy agenda. Domestic anti-tobacco groups have the motivation but not the resources to ensure the acceptance of tobacco control ideas within their political systems.

In this context, the book identifies the role of international action to close the gap between ‘leading’ and ‘laggard’ countries – a gap which is often linked specifically (but not exclusively) to the fortunes of developed/ developing countries. In particular, the World Health Organisation (WHO) Framework Convention for Tobacco Control has 175 ‘Parties’ (174 countries plus the European Union). The FCTC represents a significant short-term success, because it commits a huge number of countries to comprehensive tobacco control. However, we describe it largely as a tool for agenda-setting rather than a guarantee of long term policy implementation.

Our current work, based on the book and subsequent articles, highlights one of life’s ironies: the countries best placed to deliver on their treaty commitments are the ones which don’t need a treaty so much. They are already well on the road towards comprehensive tobacco control. In contrast, the countries that do need the treaty are the least likely to deliver its aims. This argument is backed up by statistics that we are currently gathering (ooh, the excitement of anticipation) and expert surveys like the one produced by Warner and Tam. We make this argument on the basis of the 5 factors outlined above, which help us identify an unfavourable environment in which to implement the FCTC.

Consider, for example, the experience of China as the world’s largest tobacco using and producing population (one third of the world’s smokers and 38% of tobacco production) (see a paper by Jin). It maintains a state monopoly over tobacco production which provides 8-11% of government revenue. Tobacco control is low on the domestic policy agenda and the health image competes with an unusually strong economic image based on the importance of its tobacco industry and economic growth to the legitimacy of the Chinese government. Tobacco policy (and the implementation of the FCTC) is led by an economic development agency which consults regularly with the tobacco industry, and the health ministry is ‘sidelined’. Public health groups are neither well resourced nor engaged. Public *and physician* knowledge of tobacco harm is low and smoking rates are very high among the police force held responsible for the implementation of bans on smoking in public places. If we combine these factors, we can reasonably expect much slower progress towards comprehensive tobacco control than in (say) the UK even though both have signed up to the same agreement.

Overall, we should not take comprehensive tobacco control for granted. If we live in countries like the UK we are starting to take it for granted, and may even come to accept new measures such as bans on smoking among foster parents and/ or in cars. If we travel elsewhere and smell smoke indoors, we should be quickly reminded that tobacco control varies markedly across the globe, and is likely to vary for decades to come.

‘Global Tobacco Control’ book as read by Abraham Lincoln

I wonder if anyone would be more likely to read this book if they heard the first 1500 words read by a slightly animated Abraham Lincoln in front of the White House .  If so, you can read along here (‘click to look inside’).  I also put it on youtube and it currently has 0 views.