Comparing global alcohol and tobacco control efforts: network formation and evolution in international health governance

"I Thought Cancer was a Tobacco Issue": Perspectives of Veterans with and without HIV on Cancer and Other Health Risks Associated with Alcohol and Tobacco/Nicotine Use

U.S. Veterans and people living with HIV (PWH) experience higher rates of unhealthy alcohol and tobacco/nicotine use than non-Veterans and people without HIV (PWoH). Both groups are susceptible to adverse health outcomes associated with alcohol and tobacco/nicotine use. We explored awareness of alcohol- and tobacco/nicotine-related cancer and immune health risks among Veterans Health Administration (VA) patients with and without HIV. Among a sample of 41 (46% PWH; 73% male; 39% Black) purposively-selected VA patients receiving care 2020-2021 we conducted semi-structured interviews via telephone; interviews were recorded, transcribed and analyzed using a Rapid Assessment Process. Purposive selection was based on HIV status, alcohol and/or tobacco/nicotine use, and demographics. Among participants, 66% reported current smoking, and most screened positive for unhealthy alcohol use. Participants had high awareness of cancer and other health risks related to smoking but low awareness of synergistic risks and cancer risks associated with alcohol use despite awareness of a range of other alcohol-related risks. Awareness of alcohol and/or tobacco/nicotine's impacts on the immune system was variable. Findings did not distinctly differ between PWH and PWoH. Low awareness of alcohol-related cancer risk, risks of co-occurring use, and varying awareness of the impacts of alcohol and tobacco/nicotine on the immune system suggest a need for improved messaging regarding substance use-related cancer and immune risk. This may be especially important among PWH, for whom the prevalence and adverse effects of alcohol and tobacco use, and immune dysfunction are higher.

Tobacco use and behaviour among South African adolescents and young adults: systematic review and meta-analysis

OBJECTIVE

Tobacco use, particularly the initiation of smoking during adolescence and young adulthood, represents a significant public health concern in South Africa. This study aims to conduct a comprehensive review of published literature about tobacco use and behaviour among adolescents and young adults and to determine an aggregated prevalence estimate of tobacco use within this demographic.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus and Google Scholar were searched from 1 January 2000 through 31 October 2023.

ELIGIBILITY CRITERIA

Studies were eligible for inclusion if they were cross-sectional studies conducted in South Africa and measured the prevalence and determinants of tobacco use among adolescents and young adults aged 12-24 years.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted information for each article and saved it into an Excel spreadsheet. Risk of bias analysis was conducted using the Risk of Bias Assessment Tool for non-randomised studies. The methodology quality of each selected study was evaluated using the Joanna Briggs Institute checklist. The heterogeneity of prevalence estimates was assessed using I2 statistic (random-effects DerSimonian-Laid approach).

RESULTS

Out of 73 articles identified, 12 articles were included in the analysis. The pooled prevalence of current tobacco use among South African adolescents and young adults was estimated to be 22%. The pooled prevalence of tobacco use among school dropouts, university students and secondary school learners was 51%, 20% and 16%, respectively. Stratifying using gender, boys (26%) were two times more likely to use tobacco than girls (13%).

CONCLUSION

The elevated occurrence of tobacco usage among South African adolescents and young adults is a relevant public health concern. There is a need for more population-based prevalence studies at a national level to estimate the burden of tobacco use in South Africa.

PROSPERO REGISTRATION NUMBER

CRD42023428369.

Generating political priority for alcohol policy reform: A framework to guide advocacy and research

INTRODUCTION

While effective policies exist to reduce alcohol-related harm, political will to enact them is low in many jurisdictions. We aimed to identify key barriers and strategies for strengthening political priority for alcohol policy reform.

METHODS

A framework synthesis was conducted, incorporating relevant theory, key informant interviews (n = 37) and a scoping review. Thematic analysis informed the development of a framework for understanding and influencing political priority for alcohol policy.

RESULTS

Twelve barriers and 14 strategies were identified at multiple levels (global, national and local). Major barriers included neoliberal or free trade ideology, the globalised alcohol industry, limited advocate capacity and the normalisation of alcohol harms. Strategies fell into two categories: sector-specific and system change initiatives. Sector-specific strategies primarily focus on influencing policymakers and mobilising civil society. Examples include developing a clear, unified solution, coalition building and effective framing. System change initiatives target structural change to reduce the power imbalance between industry and civil society, such as restricting industry involvement in policymaking and securing sustainable funding for advocacy. A key example is establishing an international treaty, similar to the Framework Convention on Tobacco Control, to support domestic policymaking.

DISCUSSION AND CONCLUSIONS

Our findings provide a framework for understanding and advancing political priority for alcohol policy. The framework highlights that progress can be achieved at various levels and through diverse groups of actors. The importance of upstream drivers of policymaking was a key finding, presenting challenges for time-poor advocates, but offering potential facilitation through effective global leadership.

Framing health taxes: learning from low- and middle-income countries

Health taxes are effective policy instruments to save lives, raise government revenues and improve equity. Health taxes, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy. Yet, little is known about which frames resonate in which settings and how framing can most effectively advance or limit policies. To fill this gap, we conducted qualitative research in 2022, including focus group discussions, in-depth interviews, document reviews and media analysis on the political economy of health taxes across eight low-income and middle-income countries. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Findings suggest that no single frame dominates; in fact, a plurality of different frames exist and shape discourse and policymaking. There was no clear trade-off between health and economic framing of health tax policy proposals, nor a straightforward way to handle concerns around earmarking. Understanding how to best position health taxes can empower health policymakers with more persuasive framings for health taxes and can support them to develop broader coalitions to advance health taxes. These insights can improve efforts to advance health taxes by better appreciating political economy factors and constraining corporate power, ultimately leading to improved population-level health.

Prevalence and Associated Factors of Cigarette Smoking among South African Adolescents and Young Adults: A Systematic Review and Meta-Analysis Protocol

Tobacco use, particularly the initiation of smoking during adolescence and young adulthood, represents a significant public health concern in South Africa. The influence of socio-cultural factors, marketing strategies of the tobacco industry, and accessibility of tobacco products have all been implicated in this context. This systematic review and meta-analysis protocol aims to scrutinise the body of literature on this issue, providing a comprehensive understanding of the patterns and determinants of tobacco use among South African adolescents and young adults, with an eye towards informing more effective policy interventions. The available literature for studies on tobacco use will be systematically searched and reviewed. Five international scholarly databases, namely PubMed, MEDLINE, EMBASE, Global Health, and Scopus, will be searched. Peer-reviewed studies will be included if they are conducted in South Africa or South African provinces and if they include the prevalence of tobacco use among adolescents and young adults aged between 12 and 24 years. The results of such an analysis can guide future policy designs, enabling them to be more targeted and thus more effective. The findings can also have implications for shaping global tobacco control strategies, given the transferability of successful interventions across different populations and cultural contexts. This protocol has been registered in the PROSPERO database (ID: CRD42023428369).

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Alcohol and Public Health: Failure and Opportunity

Policy Points Public health science regarding alcohol consumption and problems, alcohol's role in equity and social justice, and identification of effective policy interventions has grown steadily stronger in the past 30 years. Progress on effective alcohol policies has stalled or gone backward in the United States and much of the world. Because alcohol influences at least 14 of the 17 sustainable development goals, as well as more than 200 disease and injury conditions, reducing alcohol problems should offer a platform for collaboration across public health silos but will require that public health itself respect and follow its own science.

Understanding why collective action resulted in greater advances for tobacco control as compared to alcohol control during the Philippines' Sin Tax Reform: a qualitative study

BACKGROUND AND AIMS

In 2012, the Philippines passed a law popularly known as the 'Sin Tax Reform'. This law increased excise tax on both tobacco and alcohol. While a victory for public health, the total amount of taxes paid by the tobacco and alcohol industries was an uneven 69-31 split. The primary aim of this study is to explore why collective action of Sin Tax proponents resulted in greater advances for tobacco control as compared with alcohol control.

METHODS

A case study approach was used. Key informant interviews were carried out with 25 individuals from academic, governmental, non-governmental and international organisations and industry who had first-hand knowledge of the Sin Tax policy process, led an organisation that participated in the process and/or possessed expert knowledge of Sin Taxes in the Philippines. Interviews were subsequently transcribed then analysed using inductive coding.

RESULTS

Four factors contributed to the varying tax treatment of the two industries: (1) absence of advocacy-oriented alcohol control groups, (2) the proponents' 'divide and conquer' strategy, which aimed to prevent the alcohol and tobacco industries from joining forces, (3) the perception that moderate drinking is acceptable among some of the Sin Tax proponents, public and medical community and (4) a weaker global push for alcohol control.

CONCLUSIONS

Our findings suggest the need to cultivate advocacy-oriented alcohol control civil society organisations, generate consensus at the local and global level regarding the problem definition and policy solutions for alcohol control and consider global instruments to strengthen norms and standards for alcohol control. Given that proponents also negotiated for a lower alcohol tax compared with tobacco due to the concern that the two industries might join forces, it also raises the question of whether or not a health tax bill should tackle more than one health harming product at a time.

Drink, but don't drive? The alcohol industry's involvement in global road safety

Drink-driving is a major cause of global road traffic fatalities, yet few countries have laws that meet international best practices. One possible reason is the alcohol industry’s opposition to meaningful policies that are perceived to directly threaten sales. Our primary objectives are to document alcohol industry involvement in global road safety policies and programmes and to critically evaluate the responses of public health and road safety communities to this involvement. Under the guidance of the Policy Dystopia Model, we used a mixed methods approach in which data were gathered from expert interviews and a mapping review of 11 databases, 5 watchdog websites and 7 alcohol industry-sponsored initiatives. Triangulation was used to identify points of convergence among data sources. A total of 20 expert interviews and 94 documents were analysed. Our study showed that the alcohol industry acknowledges that drink-driving is an issue but argues for solutions that would limit impact on sales, akin to the message ‘drink—but do not drive’. Industry actors have been involved in road safety through: (1) coalition coupling and decoupling, (2) information production and management, (3) direct involvement in policymaking and (4) implementation of interventions. Our study also shed light on the lack of cohesion within and among the public health and road safety communities, particularly with regard to the topics of receiving funding from and partnering with the alcohol industry. These results were subsequently used to adapt the Policy Dystopia Model as a conceptual framework that illustrates the ways in which the alcohol industry has been involved in global road safety. Several implications can be drawn from this study, including the urgent need to increase awareness about the involvement of the alcohol industry in road safety and to build a cohesive transnational alcohol control advocacy alliance to curb injuries and deaths related to drink-driving.

The rise and fall of global health issues: an arenas model applied to the COVID-19 pandemic shock

Background

The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to make claims about the agenda status of issues. We draw on Kingdon’s definition of the agenda and Hilgartner and Bosk’s public arenas model to conceptualize the global health agenda as those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at any given time. We propose an arenas model for global health agenda setting and illustrate its potential utility by assessing priority indicators in five arenas, including international aid, pharmaceutical industry, scientific research, news media and civil society. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer’s disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19).

Results

Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events. The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other issues showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases suggesting that the agenda for global health issues expanded in some arenas in 2020— COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer’s disease, though it might have for other issues.

Conclusions

We advance an arenas model as a novel means of addressing conceptual and measurement challenges that often undermine the validity of claims concerning the global health agenda status of problems and contributing causal factors. Our presentation of the model and illustrative analysis lays the groundwork for more systematic investigation of trends in global health agenda setting. Further specification of the model is needed to ensure accurate representation of vital national and transnational arenas and their interactions, applicability to a range of disease-specific, health systems, governance and policy issues, and sensitivity to subtler influences on global health agenda setting than pandemic shocks.

Exploring mechanisms that explain how coalition groups are formed and how they work to sustain political priority for maternal and child health in Nigeria using the advocacy coalition framework

Background

The unacceptably high rate of maternal and child mortality in Nigeria prompted the government to introduce a free maternal and child health (MCH) programme, which was stopped abruptly following a change in government. This triggered increased advocacy for sustaining MCH as a political priority in the country and led to the formation of advocacy coalitions. This study set out to explain the process involved in the formation of advocacy coalition groups and how they work to bring about sustained political prioritization for MCH in Nigeria. It will contribute to the understanding of the Nigerian MCH sector subsystem and will be beneficial to health policy advocates and public health researchers in Nigeria.

Methods

This study employed a qualitative case study approach. Data were collected using a pretested interview guide to conduct 22 in-depth interviews, while advocacy events were reviewed pro forma. The document review was analysed using the manual content analysis method, while qualitative data audiotapes were transcribed verbatim, anonymized, double-coded in MS Word using colour-coded highlights and analysed using manual thematic and framework analysis guided by the advocacy coalition framework (ACF). The ACF was used to identify the policy subsystem including the actors, their belief, coordination and resources, as well as the effects of advocacy groups on policy change. Ethics and consent approval were obtained for the study.

Results

The policy subsystem identified the actors and characterized the coalitions, and described their group formation processes and resources/strategies for engagement. The perceived deep core belief driving the MCH agenda is the right of an individual to health. The effects of advocacy groups on policy change were identified, along with the factors that enabled effectiveness, as well as constraints to coalition formation. External factors and triggers of coalition formation were identified to include high maternal mortality and withdrawal of the free MCH programme, while the contextual issues were the health system issues and the socioeconomic factors affecting the country.

Conclusion

Our findings add to an increasing body of evidence that the use of ACF is beneficial in exploring how advocacy coalitions are formed and in identifying the effects of advocacy groups on policy change.

Maternal Tobacco and Alcohol Use in Relation to Child Malnutrition in Gauteng, South Africa: A Retrospective Analysis

Tobacco and alcohol use among mothers is associated with numerous adverse consequences for affected offspring, including poor growth and development. This study determined the association between maternal tobacco and alcohol use, and malnutrition, among infants aged ≤ 12 months (n = 300), in selected health facilities situated in Gauteng, South Africa. Data on alcohol and tobacco use were collected using a validated questionnaire, in addition to mothers’ socio-demographic characteristics and obstetric history. Stunting (low height/length-for-age), underweight (low weight-for-age) and thinness (low body mass index-for-age) were calculated using z-scores based on the World Health Organization child growth standards. The association of tobacco and alcohol use with stunting, underweight and thinness was analysed using logistic regression analysis. The results showed a mean age of 29 years (24.0; 35.0) for mothers and 7.6 ± 3 months for infants, and over half of the mothers were unemployed (63%). Approximately 18.7% of mothers had used tobacco and 3% had used alcohol during pregnancy. The prevalence of current tobacco and alcohol use among mothers were estimated at 14.3% and 49.7%, respectively, and almost three-quarters (67.3%) of them were still breastfeeding during the study period. Stunting (55%) was the most prevalent malnutrition indicator among infants, while underweight was 41.7%, and thinness was 22%. Current tobacco use was associated with increased odds of being thin [OR = 2.40, 95% CI: 1.09–5.45), and after adjusting for confounders, current alcohol use was associated with the likelihood of being underweight [AOR = 1.96, 95% CI: 1.06–3.63] among infants. Future prospective cohort studies that examine growth patterns among infants who are exposed to maternal tobacco and alcohol use from the intrauterine life to infancy are necessary to inform, partly, the public health programmes, to reduce malnutrition among children.

Analysing the global health agenda: A comparison of priority for diabetes and oral diseases

Many claims are made concerning which issues are on the global health agenda and which are neglected. Scholarship is inconsistent and generally vague about how an issue's status is (or should be) measured, however, leaving such claims open to questions about their validity. This inquiry explores a novel way of addressing the largely overlooked matter of how to comparatively assess the agenda status of health issues systematically, over time and in consideration of a global health context that lacks centralised authority. We draw upon a model from sociology which proposes that collective definitions of social problems and public attention evolve in multiple, interacting institutional arenas, each of which has the capacity to give robust attention to a limited number of issues. We systematically track status indicators for two significant global health issues, diabetes and oral diseases, in three arenas since 2000. Oral health's status declined while diabetes rose in international representation, international organisation and scientific research arenas during the past decade. This article sets out some preliminary contours of an analytical approach that holds promise for enhancing understanding of causal mechanisms and outcomes across a wider set of global health issues and agenda setting arenas.

A renewed call for transdisciplinary action on NCDs

Notwithstanding COVID-19, non-communicable diseases (NCDs) will be the leading cause of death in every region in the world by 2030. This contribution, which forms an introduction to our collection of articles in this journal, identifies elements for a transdisciplinary research agenda between law, public health, health economics and international relations aimed at designing concrete interventions to curb the NCD pandemic, both globally and domestically.

International norm development and change: can international law play a meaningful role in curbing the lifestyle disease pandemic?

BACKGROUND

The magnitude of the noncommunicable epidemic is difficult to overstate. The projected cost of the epidemic is substantial. It disproportionately affects people in low- and middle-income countries as well as poorer and marginalised communities in high-income countries. The international community has taken various steps to address the four modifiable risk factors causing the majority of noncommunicable diseases (NCDs), however, action has so far fallen short of expectations. Both analysts and international institutions are advocating the adoption of a new international legal norm to address the NCD crisis.

MAIN TEXT

Drawing on existing knowledge from international relations and international legal studies, this article argues that a new international treaty is not only currently improbable, but also not strictly desirable. In-depth critical analysis and reflection is needed regarding the strengths and weaknesses of a legal approach to addressing the NCD pandemic. The argument is set out in three sections - the first reviews contributions of agentic constructivism, which focus on the process of normative emergence and change, and draws on empirical examples to highlight overlooked aspects of normative development and how they relate to NCD politics. The second engages with the critique of legal principles. Critical approaches to law seek to expose the myths that legal principles are neutral, objective, good. The third section discusses the characteristics of practice in the NCD field and its implications on process and principles for the pursuit of a legal solution to the NCD crisis.

CONCLUSIONS

Any advocacy for an international norm to address NCDs needs to be nuanced and demonstrate awareness of the nature and character of both the norm development process and resulting international legal principles. As analysts, we are responsible for advocating inclusive and ethical norms, but also for highlighting the implications of inequalities and differences between and within states and societies. There may be a viable international legal instrument that would support dedicated policies to curb the NCD epidemic, but such an instrument needs to be actively advocated for and negotiated with a wide range of stakeholders, navigating a complex international framework of existing norms and conflicting, powerful interests.

Global Health diplomacy for noncommunicable diseases prevention and control: a systematic review

INTRODUCTION

The prevention and control of noncommunicable diseases (NCDs) are one of the main challenges of healthcare systems around the world. In addition to the technical level, it requires political negotiations and solutions, such as global health diplomacy (GHD), which involves the participation of a wide range of actors and stakeholders and innovative international health partnerships. This review aimed to draw lessons for strengthening linkages with a wide range of actors and stakeholders from the GHD literature for NCDs, and how policymakers and political leaders can effectively use international health partnerships to beat NCDs.

METHODS

This research was a systematic review of the literature on GHD for NCDs. All relevant articles published in English were identified by searching PubMed, Web of Science, Scopus, and Embase databases, Google and Google Scholar search engines, and the reference lists of identified articles as well as a number of special journals. 30 articles that met the inclusion criteria were analyzed using content analysis in MAXQDA 10. The Global Health Diplomacy Pyramid and Blouin and Dubé's (2010) analytical framework for examining negotiations were used to classify the data.

FINDINGS

30 articles have been published on GHD for NCDs. Five key themes, i.e. the specific problem requiring global collective action, key actors, their interests in the problem, potential negotiation process, and potential scenarios for collective action and 46 sub-themes were identified. Moreover, given the importance of collaboration on NCDs in the international arena, actors were categorized into three groups based on the GHD Pyramid: (1) core diplomacy, (2) multi-stakeholder diplomacy, and (3) informal diplomacy.

CONCLUSION

Development and adoption of a global policy to tackle the rise in NCDs in developed and developing countries require policymakers and political leaders that participate in GHD. Successful developments in global health policy depend on the performance of and respectful relationships among the stakeholders, and global health diplomats need to understand the complexities of the institutional structures and functional relationships of the international institutions involved in health.

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study

BACKGROUND

Despite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.

METHODS

We used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.

FINDINGS

Several factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.

CONCLUSION

In order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise.

Neurochemical mechanisms underlying acute and chronic ethanol-mediated responses in zebrafish: The role of mitochondrial bioenergetics

Ethanol (EtOH) is a socially-accepted drug, whose consumption is a risk factor for non-intentional injuries, development of pathologies, and addiction. In the brain, EtOH affects redox signaling and increases reactive oxygen species (ROS) production after acute and chronic exposures. Here, using a high-resolution respirometry assay, we investigated whether changes in mitochondrial bioenergetics play a role in both acute and chronic EtOH-mediated neurochemical responses in zebrafish. For the first time, we showed that acute and chronic EtOH exposures differently affect brain mitochondrial function. Acutely, EtOH stimulated mitochondrial respiration through increased baseline state, CI-mediated OXPHOS, OXPHOS capacity, OXPHOS coupling efficiency, bioenergetic efficiency, and ROX/ETS ratio. Conversely, EtOH chronically decreased baseline respiration, complex I- and II-mediated ETS, as well as increased ROX state and ROX/ETS ratio, which are associated with ROS formation. Overall, we observed that changes in mitochondrial bioenergetics play a role, at least partially, in both acute and chronic effects of EtOH in the zebrafish brain. Moreover, our findings reinforce the face, predictive, and construct validities of zebrafish models to explore the neurochemical bases involved in alcohol abuse and alcoholism.

New and Emerging Tobacco Products and the Nicotine Endgame: The Role of Robust Regulation and Comprehensive Tobacco Control and Prevention: A Presidential Advisory From the American Heart Association

The advent of new tobacco products such as electronic cigarettes and the dramatic rise in their use, especially by adolescents and young adults, are significant public health concerns. Electronic cigarettes have become the most popular tobacco products for youth and adolescents in the United States and are attracting youth to new avenues for nicotine addiction. Although these products may have benefit by helping some smokers quit or to move to a less harmful product, the long-term health effects of these products and the net public health effect associated with their use remain unclear and widely debated. There is increasing concern that the use of newer tobacco products may catalyze transition to the use of other tobacco products or recreational drugs, particularly in young adults. Therefore, there is urgent need for robust US Food and Drug Administration regulation of all tobacco products to avoid the significant economic and population health consequences of continued tobacco use. Although the American Heart Association acknowledges that the ultimate endgame would be an end to all tobacco and nicotine addiction in the United States, it supports first minimizing the use of all combustible tobacco products while ensuring that other products do not addict the next generation of youth and adolescents. The endgame strategy needs to be coordinated with the long-standing, evidence-based tobacco control strategies that have significantly reduced tobacco use and initiation in the United States.

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.

Civil society in global health policymaking: a critical review

BACKGROUND

A social science approach to the study of civil society's role and influence in global health policymaking is a new area of scholarly research. In this article, I conduct a critical literature review to assess the recent research done on this topic.

MAIN BODY

I find that most research has been narrowly focused on the agenda-setting and policy implementation stages, failing to account for all stages of the policymaking process and civil society's role in it. Additionally, very little effort has been made to test and develop theoretical and analytical policymaking frameworks, clearly and consistently defining and conceptualizing civil society's role and influence in global health policymaking, provide methodological specificity and diversity, while emphasizing the importance of causal mechanisms.

CONCLUSION

I conclude by encouraging scholars to address these lacuna in the literature and to explore the utility of political science theory and alternative policymaking models to better define and explain the complexity of civil society's role and influence in global health policymaking processes.

Adopting New International Health Instruments - What Can We Learn From the FCTC? Comment on "The Legal Strength of International Health Instruments - What It Brings to Global Health Governance?"

This Commentary forms a response to Nikogosian's and Kickbusch's forward-looking perspective about the legal strength of international health instruments. Building on their arguments, in this commentary we consider what we can learn from the Framework Convention on Tobacco Control (FCTC) for the adoption of new legal international health instruments.

Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries

Tobacco is widely considered to be a uniquely harmful product for human health. Since the mid-1990s, the strategies of transnational tobacco corporations to undermine effective tobacco control policy has been extensively documented through internal industry documents. Consequently, the sale, use and marketing of tobacco products are subject to extensive regulation and formal measures to exclude the industry from policy-making have been adopted in the Framework Convention on Tobacco Control. In contrast to tobacco, alcohol is subject to less stringent forms of regulation, and the alcohol industry continues to play a central role in policy-making in many countries and at the global level. This article examines whether there is a sufficient rationale for such different regulatory approaches, through a comparative analysis of the political economy of the tobacco and alcohol industries including the structure of the industries, and the market and political strategies they pursue. Despite some important differences, the extensive similarities which exist between the tobacco and alcohol industries in terms of market structure and strategy, and political strategy, call into question the rationale for both the relatively weak regulatory approach taken towards alcohol, and the continued participation of alcohol corporations in policy-making processes.

Four Challenges That Global Health Networks Face

Global health networks, webs of individuals and organizations with a shared concern for a particular condition, have proliferated over the past quarter century. They differ in their effectiveness, a factor that may help explain why resource allocations vary across health conditions and do not correspond closely with disease burden. Drawing on findings from recently concluded studies of eight global health networks—addressing alcohol harm, early childhood development (ECD), maternal mortality, neonatal mortality, pneumonia, surgically-treatable conditions, tobacco use, and tuberculosis—I identify four challenges that networks face in generating attention and resources for the conditions that concern them. The first is problem definition: generating consensus on what the problem is and how it should be addressed. The second is positioning: portraying the issue in ways that inspire external audiences to act. The third is coalition-building: forging alliances with these external actors, particularly ones outside the health sector. The fourth is governance: establishing institutions to facilitate collective action. Research indicates that global health networks that effectively tackle these challenges are more likely to garner support to address the conditions that concern them. In addition to the effectiveness of networks, I also consider their legitimacy, identifying reasons both to affirm and to question their right to exert power.

Setting the global health agenda: The influence of advocates and ideas on political priority for maternal and newborn survival

This study investigates a puzzle concerning global health priorities-why do comparable issues receive differential levels of attention and resources? It considers maternal and neonatal mortality, two high-burden issues that pertain to groups at risk at birth and whose lives could be saved with effective intrapartum care. Why did maternal survival gain status as a global health priority earlier and to a greater degree than newborn survival? Higher mortality and morbidity burdens among newborns and the cost-effectiveness of interventions would seem to predict that issue's earlier and higher prioritization. Yet maternal survival emerged as a priority two decades earlier and had attracted considerably more attention and resources by the close of the Millennium Development Goals era. This study uses replicative process-tracing case studies to examine the emergence and growth of political priority for these two issues, probing reasons for unexpected variance. The study finds that maternal survival's grounding as a social justice issue spurred growth of a strong and diverse advocacy network and aligned the issue with powerful international norms (e.g. expectations to advance women's rights and the Millennium Development Goals), drawing attention and resources to the issue over three decades. Newborn survival's disadvantage stems from its long status as an issue falling under the umbrellas of maternal and child survival but not fully adopted by these networks, and with limited appeal as a public health issue advanced by a small and technically focused network; network expansion and alignment with child survival norms have improved the issue's status in the past few years.

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

In recent years, tobacco control emerged as a political priority in Turkey and today the country is widely regarded as one of the global leaders in tackling tobacco use. Although political priority is considered a facilitating factor to the success of addressing public health issues, there is a paucity of research to help us understand how it is developed in middle-income countries. The primary aim of this study is to understand the process and determinants of how tobacco control became a political priority in Turkey using the Multiple Streams Framework. A mixed-methods case study approach was used whereby data were gathered from three different sources: in-depth interviews (N = 19), document reviews (N = 216), and online self-administered surveys (N = 61). Qualitative data were collected for the purpose of understanding the processes and determinants that led to political prioritization of tobacco control and were analyzed using deductive and inductive coding. Quantitative data were collected to examine the actors and were analyzed using descriptive statistics and network nominations. Data were triangulated. Findings revealed that tobacco control achieved political priority in Turkey as a result of the development and convergence of multiple streams, including a fourth, separate global stream. Findings also shed light on the importance of Turkey's foreign policy in the transformation of the political stream. The country's desire for European Union accession and global visibility helped generate a political environment that was receptive to global norms for tobacco control. A diverse but cohesive network of actors joined forces with global allies to capitalize on this opportunity. Results suggest (1) the importance of global-agenda setting activities on political priority development, (2) the utility of aligning public health and foreign policy goals and (3) the need to build a strong global incentive structure to help entice governments to take action on public health issues.

A framework on the emergence and effectiveness of global health networks

Since 1990 mortality and morbidity decline has been more extensive for some conditions prevalent in low- and middle-income countries than for others. One reason may be differences in the effectiveness of global health networks, which have proliferated in recent years. Some may be more capable than others in attracting attention to a condition, in generating funding, in developing interventions and in convincing national governments to adopt policies. This article introduces a supplement on the emergence and effectiveness of global health networks. The supplement examines networks concerned with six global health problems: tuberculosis (TB), pneumonia, tobacco use, alcohol harm, maternal mortality and newborn deaths. This article presents a conceptual framework delineating factors that may shape why networks crystallize more easily surrounding some issues than others, and once formed, why some are better able than others to shape policy and public health outcomes. All supplement papers draw on this framework. The framework consists of 10 factors in three categories: (1) features of the networks and actors that comprise them, including leadership, governance arrangements, network composition and framing strategies; (2) conditions in the global policy environment, including potential allies and opponents, funding availability and global expectations concerning which issues should be prioritized; (3) and characteristics of the issue, including severity, tractability and affected groups. The article also explains the design of the project, which is grounded in comparison of networks surrounding three matched issues: TB and pneumonia, tobacco use and alcohol harm, and maternal and newborn survival. Despite similar burden and issue characteristics, there has been considerably greater policy traction for the first in each pair. The supplement articles aim to explain the role of networks in shaping these differences, and collectively represent the first comparative effort to understand the emergence and effectiveness of global health networks.

The emergence and effectiveness of global health networks: findings and future research

Global health issues vary in the amount of attention and resources they receive. One reason is that the networks of individuals and organizations that address these issues differ in their effectiveness. This article presents key findings from a research project on the emergence and effectiveness of global health networks addressing tobacco use, alcohol harm, maternal mortality, neonatal mortality, tuberculosis and pneumonia. Although networks are only one of many factors influencing priority, they do matter, particularly for shaping the way the problem and solutions are understood, and convincing governments, international organizations and other global actors to address the issue. Their national-level effects vary by issue and are more difficult to ascertain. Networks are most likely to produce effects when (1) their members construct a compelling framing of the issue, one that includes a shared understanding of the problem, a consensus on solutions and convincing reasons to act and (2) they build a political coalition that includes individuals and organizations beyond their traditional base in the health sector, a task that demands engagement in the politics of the issue, not just its technical aspects. Maintaining a focused frame and sustaining a broad coalition are often in tension: effective networks find ways to balance the two challenges. The emergence and effectiveness of a network are shaped both by its members' decisions and by contextual factors, including historical influences (e.g. prior failed attempts to address the problem), features of the policy environment (e.g. global development goals) and characteristics of the issue the network addresses (e.g. its mortality burden). Their proliferation raises the issue of their legitimacy. Reasons to consider them legitimate include their members' expertise and the attention they bring to neglected issues. Reasons to question their legitimacy include their largely elite composition and the fragmentation they bring to global health governance.

The global health network on alcohol control: successes and limits of evidence-based advocacy

Global efforts to address alcohol harm have significantly increased since the mid-1990 s. By 2010, the World Health Organization (WHO) had adopted the non-binding Global Strategy to Reduce the Harmful Use of Alcohol. This study investigates the role of a global health network, anchored by the Global Alcohol Policy Alliance (GAPA), which has used scientific evidence on harm and effective interventions to advocate for greater global public health efforts to reduce alcohol harm. The study uses process-tracing methodology and expert interviews to evaluate the accomplishments and limitations of this network. The study documents how network members have not only contributed to greater global awareness about alcohol harm, but also advanced a public health approach to addressing this issue at the global level. Although the current network represents an expanding global coalition of like-minded individuals, it faces considerable challenges in advancing its cause towards successful implementation of effective alcohol control policies across many low- and middle-income countries (LMICs). The analysis reveals a need to transform the network into a formal coalition of regional and national organizations that represent a broader variety of constituents, including the medical community, consumer groups and development-focused non-governmental organizations. Considering the growing harm of alcohol abuse in LMICs and the availability of proven and cost-effective public health interventions, alcohol control represents an excellent 'buy' for donors interested in addressing non-communicable diseases. Alcohol control has broad beneficial effects for human development, including promoting road safety and reducing domestic violence and health care costs across a wide variety of illnesses caused by alcohol consumption.