"Quitting like a Turk:" How political priority developed for tobacco control in Turkey

Assessing the contributions of an urban population health initiative to shift political priority towards cardiovascular health: three case studies from Brazil, Mongolia and Senegal

BACKGROUND

The urban population health initiative was designed as a multidisciplinary, multisector programme to address cardiovascular (CV) disease, specifically hypertension and its underlying causes in the cities of Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. This article aims to provide an overview of the history and dynamics of CV disease policy making in the three countries, to present the policy reform contributions of the initiative and its role in the policy agenda-setting framework/process in each country and to identify the enablers and challenges to the initiative for doing so.

METHODS

A qualitative case study was conducted for each setting from November 2020 to January 2021, comprised of a document review, semi-structured in-depth interviews and unstructured interviews with stakeholders involved in the initiative. The literature review included documents from the initiative and the peer-reviewed and grey literature with a total of 188 documents screened. Interviews were conducted with 21 stakeholders. Data collection and thematic analysis was guided by (i) the Kingdon multiple streams conceptual framework with the main themes being CV disease problems, policy, politics and the role of policy entrepreneurs; and (ii) the study question inquiring on the role of the urban population health initiative at the CV disease policy level and enabling and challenging factors to advancing CV disease policy. Data were thematically analysed using the Framework Method.

RESULTS

Each setting was characterized by a high hypertension and CV disease burden combined with an aware and proactive political environment. Policy outcomes attributed to the initiative were updating the guidelines and/or algorithms of care for hypertension and including revised physical and nutritional education in school curricula, in each city. Overall, the urban health initiative's effects in the policy arena, were most prominent in Mongolia and Senegal, where the team effectively acted as policy entrepreneur, promoting the solutions/policies in alignment with the most pressing local problems and in strong involvement with the political actors. The initiative was also involved in improving access to CV disease drugs at primary health levels. Its success was influenced by the local governance structures, the proximity of the initiative to the policy makers and the local needs. In Brazil, needs were expressed predominantly in the clinical practice.

CONCLUSIONS

This multi-country experience shows that, although the policy and political environment plays its role in shaping initiatives, often the local priority needs are the driving force behind wider change.

Multiple streams approach to tobacco control policymaking in the capital city of the world's largest tobacco consuming country

The aim of this study was to analyse the policymaking process of Beijing tobacco control regulations based on a multiple streams framework to provide a reference for other cities, at the national level and for the international community to promote the development of tobacco control policy. Twenty-one documents related to tobacco control in Beijing were collected, nine informants were interviewed and the interview data were analysed by a thematic framework method. It was found that indicators, feedback and a focus event in the problem stream drew the attention of policymakers and the society for tobacco control. In 2011, Ying Songnian, a representative of the Beijing Municipal People's Congress, put forward tobacco control legislation, which was just in time for the legislative reform of the Congress. The proposal was studied by the Congress, and a strategy of 'social co-governance' was founded. In the political stream, the government actively promoted tobacco control and social organizations extensively participated in it. In 2013, the General Office of the Central Committee of the Chinese Communist Party and the General Office of the State Council issued a notice on matters related to leading cadres taking the lead in banning smoking in public places, which opened a policy window for decision-makers who were hesitatant. The issue of tobacco control was successfully put on the policy agenda and contributed to the introduction of the Beijing Municipal Regulations on Smoking Control. Development of the factors in problem stream, policy stream and political stream promoted the setting up of the tobacco control policy agenda in Beijing. It is suggested that more cities should learn from the experience of Beijing, seize the opportunity of the ideological change of the ruling party, actively identify the problems, mobilize and advocate for representatives and introduce the concept of 'social co-governance' to promote tobacco control legislation.

Health Taxes on Tobacco, Alcohol, Food and Drinks in Low- and Middle-Income Countries: A Scoping Review of Policy Content, Actors, Process and Context

BACKGROUND

Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs.

METHODS

This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O'Malley's scoping review methodology and Walt and Gilson's policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures.

RESULTS

We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors - rather than the presence or absence of particular factors - has the most profound impact on policy implementation.

CONCLUSION

Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.

Two steps forward, one step back: the lead up to tobacco plain packaging policy in Turkey

The Turkish government first announced its intention to proceed with tobacco plain packaging legislation in 2011; however, it was 7 years before the legislation passed in December 2018. This study (conducted in 2018 before the legislation was passed) explored the policy context in Turkey between the first announcement that plain packaging legislation would be introduced and the passage of the legislation in 2018, and identified barriers and facilitators influencing its introduction. Publicly available documents relevant to plain packaging in Turkey were analysed. Interviews were conducted in 2018 with ten key informants including academics, bureaucrats in government ministries and leaders of non-government organizations (NGOs). Thematic analysis was undertaken, using a framework for systematically analysing how issues reach the policy agenda. The introduction of plain packaging legislation proved to be problematic, with many false starts and delays. Findings suggest these were mainly due to political barriers including changes in government, tobacco industry opposition and the national economic crisis. However, plain packaging legislation in Turkey managed to advance on the policy agenda, primarily through the collaborative advocacy efforts of NGOs, academics, and leadership from particular tobacco control advocates and politicians. Turkey's experience provides lessons for the wider uptake of tobacco plain packaging legislation, illustrating the critical importance of building effective coalitions between a range of stakeholders and political support within government while raising public awareness. Lay summary This research provides insights into the barriers and facilitators of decision making and action that shaped the process of introducing tobacco plain packaging legislation in Turkey. Major barriers that slowed Turkey's progress in enacting plain packaging included the financial and national economic crisis in 2018, changes in health ministers and opposition by the tobacco industry. A major facilitator of the policy process was the collaborative advocacy efforts of non-government organizations, academics, politicians and the leadership of certain tobacco control advocates. The insights from this case study may help other low- and middle-income countries to anticipate and successfully navigate the challenges involved in introducing tobacco plain packaging, an important policy measure for reducing the burden of tobacco-related disease in their populations, and its social and economic impacts. Building effective coalitions and fostering and supporting leadership are important strategies for the successful introduction of plain packaging legislation.

Agenda-setting of tobacco control policy in Iran: a retrospective policy analysis study

BACKGROUND

The prevalence of tobacco use, especially hookah, has increased in Iran In recent years, particularly among young people and women, and the age of onset of use has decreased. Tobacco use is the fourth leading risk factor for non-communicable diseases in Iran. These issues cause concerns in the country and led to the present study on tobacco control agenda-setting in Iran over a 30-year timeframe.

METHODS

We conducted this retrospective analytical study to investigate process analysis in Iran using Kingdon's multiple-streams framework (MSF). We collected the data using semi-structured interviews with key informants (n = 36) and reviewing policy documents (n > 100). Then, we analyzed the policy documents and in-depth interviews using the document and framework analysis method. We used MAXQDA 11 software to classify and analyze the data.

RESULTS

Iran's accession to the Framework Convention on Tobacco Control (FCTC) opened a window of opportunity for tobacco control. The policy window opens when all three streams have already been developed. The adoption of the comprehensive law on the national control and campaign against tobacco in the Islamic Consultative Assembly in 2006 is a turning point in tobacco control activities in Iran.

CONCLUSIONS

The tobacco control agenda-setting process in Iran was broadly consistent with MSF. The FCTC strengthened the comprehensive plan for national control of tobacco as a policy stream. However, there are several challenges in developing effective policies for tobacco control in the Iranian setting.

Understanding political priority development for public health issues in Turkey: lessons from tobacco control and road safety

BACKGROUND

Tobacco use and road traffic injuries are major public health problems in Turkey. During the last decade, the former issue received political priority in the country, while the latter did not despite the immense health and economic burden that road traffic injuries pose on the Turkish population. Political priority can facilitate the attainment of public health goals. Unfortunately, however, limited cross-case analyses exist to help us understand why it emerges for certain public health issues but fails to develop for others in low- and middle-income countries.

METHODS

This study utilised Kingdon's Multiple Streams Framework to explore the political priority development process in Turkey. A cross-case analysis was conducted, using data gathered from three different sources, namely key informant interviews (n = 42), documents (n = 307) and online self-administered surveys (n = 153). The Wilcoxon-Mann-Whitney test was also employed to examine whether the relationships within the tobacco control and road safety networks differed significantly.

RESULTS

In Turkey, political priority emerges when four streams - problem, policy, political and global - converge while a policy window is open. While these findings are largely consistent with the Multiple Streams Framework, this study also shed light on (1) the need to consider global health treaties for urgent public health issues as these instruments can accentuate global norms and standards, (2) the disproportionate strength of the political stream, (3) the need to develop in-depth understanding of national political context, (4) the importance of fostering meaningful ties between global and domestic health networks, and (5) the need for policy network cohesion.

CONCLUSIONS

Findings from this study can be used by advocates striving to promote public health issues in other similar contexts.

The Making of a New Medical Specialty: A Policy Analysis of the Development of Emergency Medicine in India

BACKGROUND

Medical specialization is an understudied, yet growing aspect of health systems in low- and middleincome countries (LMICs). In India, medical specialization is incrementally, yet significantly, modifying service delivery, workforce distribution, and financing. However, scarce evidence exists in India and other LMICs regarding how medical specialties evolve and are regulated, and how these processes might impact the health system. The trajectory of emergency medicine appears to encapsulate broader trends in medical specialization in India - international exchange and engagement, the formation of professional associations, and a lengthy regulatory process with the Medical Council of India. Using an analysis of political priority setting, our objective was to explore the emergence and recognition of emergency medicine as a medical specialty in India, from the early 1990s to 2015.

METHODS

We used a qualitative case study methodology, drawing on the Shiffman and Smith framework. We conducted 87 in-depth interviews, reviewing 122 documents, and observing six meetings and conferences. We used a modified version of the 'Framework' approach in our analysis.

RESULTS

Momentum around emergency medicine as a viable solution to weak systems of emergency care in India gained traction in the 1990s. Public and private sector stakeholders, often working through transnational professional medical associations, actively pursued recognition from Medical Council of India. Despite fragmentation within the network, stakeholders shared similar beliefs regarding the need for specialty recognition, and were ultimately achieved this objective. However, fragmentation in the network made coalescing around a broader policy agenda for emergency medicine challenging, eventually contributing to an uncertain long-term pathway. Finally, due to the complexities of the regulatory system, stakeholders promoted multiple forms of training programs, expanding the workforce of emergency physicians, but with limited coordination and standardization.

CONCLUSION

The ideational centrality of postgraduate medical education, a challenging national governance system, and fragmentation within the transnational stakeholder network characterized the development of emergency medicine in India. As medical specialization continues to shape and influence health systems globally, research on the evolution of new medical specialties in LMICs can enhance our understanding of the connections between specialization, health systems, and equity.

Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge

Multisectoral action is key to addressing many pressing global health challenges and critical for achieving the Sustainable Development Goals, but to-date, understanding about how best to promote and support multisectoral action for health is relatively limited. The challenges to multisectoral action may be more acute in low-income and middle-income countries (LMICs) where institutions are frequently weak, and fragmentation, even within the health sector, can undermine coordination. We apply the lens of governance to understand challenges to multisectoral action. This paper (1) provides a high level overview of possible disciplines, frameworks and theories that could be applied to enrich analyses in this field; (2) summarises the literature that has sought to describe governance of multisectoral action for health in LMICs using a simple political economy framework that identifies interests, institutions and ideas and (3) introduces the papers in the supplement. Our review highlights the diverse, but often political nature of factors influencing the success of multisectoral action. Key factors include the importance of high level political commitment; the incentives for competition versus collaboration between bureaucratic agencies and the extent to which there is common understanding across actors about the problem. The supplement papers seek to promote debate and understanding about research and practice approaches to the governance of multisectoral action and illustrate salient issues through case studies. The papers here are unable to cover all aspects of this topic, but in the final two papers, we seek to develop an agenda for future action. This paper introduces a supplement on the governance of multisectoral action for health. While many case studies exist in this domain, we identify a need for greater theory-based conceptualisation of multisectoral action and more sophisticated empirical investigation of such collaborations.

The perspectives of politicians on tobacco control in Turkey

Background

Tobacco use is a leading but preventable cause of non-communicable diseases and premature death. The legislature has a key role in setting tobacco control policies. Smoking trends are decreasing thanks to the introduction of effective tobacco control policies in Turkey and these policies may have been shaped by how politicians' interpreted social problems that were prominent during the development and implementation of tobacco regulations.

Aim

This paper explores the long-term national relationship between tobacco consumption, tobacco control policies and the associated political discourse in Turkey, considering the varying influences through national leadership on this important public health agenda. This relationship is studied by comparing a time series analysis of tobacco consumption trends with a policy analysis of the minutes of deliberations at the Grand National Assembly of Turkey (GNAT).

Methods

This study uses Bayesian time series analysis in order investigate whether the tobacco control policies and related activities influenced the annual per adult cigarette consumption in Turkey. We used a novel method to identify change points in tobacco trends and whether they correspond with key policy changes intended to alter usage after adjusting for the effect of other non-policy related covariates, such as the purchasing power. The policy analysis included an examination of the minutes of deliberations at the GNAT-which is the Turkish parliament and unicameral Turkish legislature-1 year before and 1 year after the break years associated with an increase or decrease in tobacco consumption.

Results and recommendations

Tobacco consumption increased with the encouragement of tobacco production and the entrance of multinational companies in the country in 1976 and 1993, respectively. The National Tobacco Law of 1996 and comprehensive amendments in 2008, including smoke-free public places and tax increases, appear to have helped reduce tobacco consumption in Turkey. The focus of Parliamentary discussions throughout this period changed, becoming less supportive of tobacco over time. However, throughout the period there remained discussions focussing on concerns around the implications for the economy and the privatization agenda, national agriculture and the welfare of farmers. Effective control appears to require certain political ingredients to be implemented: politicians who are well informed on tobacco control measures and understand the range of issues surrounding the policies (not only those directly health-related); and supportive public health information in the community. Evidence-based public health policy should be introduced to the politicians.

Application of policy analysis frameworks in tobacco control research: A systematic review of qualitative literature

Background: Tobacco consumption is still considered as the first preventable cause of death in the world. In order to influence tobacco policy process, researchers and policymakers must use frameworks of policy-making to understand the process to provide them insights for influence the process. This systematic review aims to review the application of policy analysis frameworks in the field of tobacco control. Methods: A systematic search for articles was performed using four databases (Ovid Medline, Scopus, Cochrane Library, and PubMed) up to December 19, 2016. The articles were selected based on inclusion and exclusion criteria. All research studies focusing on tobacco policy and on one or more specified frameworks of policy analysis included in this study. Finally, thematic analysis was used to synthesize the findings. Results: 17 studies based on eligibility criteria were included in this study. The findings of this study showed that most of the studies were in North America, published in the Health journals, conducted to analyze the national and state policies, focused on analyzing agenda-setting phase. Multiple streams model was the most widely used framework within the literature. Few studies had used advocacy coalition framework. From the three agenda setting frameworks and theories (MSF, PEF, ACF), the ACF framework is the most detailed framework in terms of elements and factors affecting the dynamics of political sub-system the reasons for models selection and suitability for the study was noted only in a small number of studies. The results of this study showed underuse and the incomplete or improper use of policy analysis models and frameworks in the field of tobacco research. Conclusion: The study showed that a number of theories and frameworks have been used but their use was limited and have significant methodological weaknesses.

Engaging nurses in smoking cessation: Challenges and opportunities in Turkey

This paper discusses the training of nurses in smoking cessation as part of routine patient care in Turkey. Formative research was carried out prior to training to identify challenges faced by smokers when trying to quit. Site visits to government hospitals and cessation clinics were conducted to observe health care provider-patient interactions involving behavior change. Four culturally sensitive cessation training workshops for nurses (n = 54) were conducted in Istanbul. Following training, nurses were debriefed on their experiences delivering cessation advice. Challenges to cessation counseling included lack of time and incentives for nurse involvement; lack of skills to deliver information about the harm of smoking and benefits of quitting; the medicalization of cessation through the use of pharmaceuticals; and hospital policy which devalues time spent on cessation activities. The pay-for-performance model currently adopted in hospitals has de-incentivized doctor participation in cessation clinics. Nurses play an important role in smoking cessation in many countries. In Turkey, hospital policy will require change so that cessation counseling can become a routine part of nursing practice, incentives for providing cessation are put in place, and task sharing between nurses and doctors is clarified. Nurses and doctors need to receive training in both the systemic harms of smoking and cessation counseling skills. Opportunities, challenges and lessons learned are highlighted.

Factors influencing the tobacco control policy process in Egypt and Iran: a scoping review

INTRODUCTION

Tobacco control policy is essential for addressing the growing tobacco consumption seen in the Eastern Mediterranean Region, the single greatest preventable contributor to the non-communicable disease epidemic. Egypt and Iran have had varied success in using policy to combat this issue. The study aims to identify and compare the factors which have influenced different stages of the policy process - evidence generation, development and implementation.

METHODS

A scoping review was conducted with a systematic search of 7 databases which was conducted along with searches of Google Scholar, and the World Health Organisation and Eastern Mediterranean Regional Office websites to identify influencing factors at each stage of the policy process.

RESULTS

Twenty-seven relevant articles were identified from the literature search. Factors identified as influencing tobacco control policy in these countries were lobbying by the tobacco industry, the rise of water-pipe smoking, lack of political commitment and the lack of resources to for policy implementation. Iran was found to be leading Egypt on all three areas of the policy process. Implementation was found to be the most pivotal part of the policy process and the area in which Egypt was weakest compared to Iran.

CONCLUSION

This study addresses a gap in knowledge concerning tobacco control in the Middle East and has identified multiple factors which are potentially slowing the process of enforcing policy to address tobacco consumption. Iran is the regional leader for tobacco control and it is important for Egypt to assess the transferability of its tactics and immediately start implementing measures to control tobacco use.